Programas de prevención familiares para el consumo de alcohol en los jóvenes
Resumen
Antecedentes
El consumo de alcohol expone a los jóvenes a un mayor riesgo de una variedad de efectos perjudiciales a corto y largo plazo y es motivo de preocupación para los servicios sanitarios, los elaboradores de políticas, los trabajadores sociales de la juventud, los profesores y los padres.
Objetivos
Evaluar la efectividad de los programas de prevención familiares universales, selectivos e indicados para prevenir el consumo de alcohol o los problemas con el alcohol en los niños de edad escolar (hasta 18 años de edad).
Específicamente, en cuanto a estos resultados, la revisión buscó:
• evaluar la efectividad de los programas de prevención familiares universales para todos los niños hasta los 18 años ("intervenciones universales");
• evaluar la efectividad de los programas de prevención familiares selectivos para niños de hasta 18 años de edad en riesgo elevado de consumo de alcohol o problemas con el alcohol ("intervenciones selectivas"); y
• evaluar la efectividad de los programas de prevención familiares indicados para niños de hasta 18 años de edad que actualmente consumen alcohol o han iniciado el consumo o el consumo habitual ("intervenciones indicadas").
Métodos de búsqueda
Se identificó evidencia relevante en el Registro Cochrane Central de Ensayos Controlados (Cochrane Central Register of Controlled Trials) (CENTRAL), en la Cochrane Library, MEDLINE (Ovid 1966 hasta junio 2018), Embase (1988 hasta junio 2018), Education Resource Information Center (ERIC; EBSCOhost; 1966 hasta junio 2018), PsycINFO (Ovid 1806 hasta junio 2018), y en Google Scholar. También se realizaron búsquedas en los registros de ensayos clínicos y búsquedas manuales de las referencias de las revisiones sistemáticas relacionadas con el tema y los estudios incluidos.
Criterios de selección
Se incluyeron ensayos controlados aleatorios (ECA) y ECA grupales que incorporaron a los padres de niños en edad escolar de la población general, sin factores de riesgo conocidos (intervenciones universales), en riesgo elevado de consumo de alcohol o problemas con el alcohol (intervenciones selectivas) o que ya eran consumidores de alcohol (intervenciones indicadas). Las intervenciones psicosociales o educativas que incorporaron a los padres con o sin participación de los niños se compararon con ninguna intervención, o con intervenciones alternativas (p.ej. niños solos), lo que permite el aislamiento experimental de los componentes de padres.
Obtención y análisis de los datos
Se utilizaron los procedimientos metodológicos estándar previstos por Cochrane.
Resultados principales
Se incluyeron 46 estudios (39 822 participantes), con 27 clasificados como universales, 12 como selectivos y siete como indicados. Se realizaron los metanálisis según el resultado, incluidos los estudios que informan sobre la prevalencia, la frecuencia o el volumen de alcohol consumido. La calidad general de la evidencia fue baja o muy baja y hubo una alta heterogeneidad no explicada.
Al comparar cualquier intervención familiar con ninguna intervención/atención estándar, no se encontró ningún efecto de la intervención sobre la prevalencia (diferencia de medias estandarizada [DME] 0,00; intervalo de confianza [IC] del 95%: ‐0,08 a 0,08; estudios = 12; participantes = 7490; I² = 57%; evidencia de baja calidad) ni la frecuencia (DME ‐0,31; IC del 95%: ‐0,83 a 0,21; estudios = 8; participantes = 1835; I² = 96%; evidencia de muy baja calidad) del consumo de alcohol en comparación con ninguna intervención/atención estándar. El efecto de cualquier intervención familiar/de padres sobre el volumen de alcohol consumido en comparación con ninguna intervención/atención estándar fue muy pequeño (DME ‐0,14; IC del 95%: ‐0,27 a 0,00; estudios = 5; participantes = 1825; I² = 42%; evidencia de baja calidad).
Cuando se compararon las intervenciones de padres/familias con las intervenciones en adolescentes versus las intervenciones con jóvenes solos, no se hallaron diferencias en la prevalencia del consumo de alcohol (DME ‐0,39; IC del 95%: ‐0,91 a 0,14; estudios = 4; participantes = 5640; I² = 99%; evidencia de muy baja calidad) ni la frecuencia (DME ‐0,16; IC del 95%: ‐0,42 a 0,09; estudios = 4; participantes = 915; I² = 73%; evidencia de muy baja calidad). Para esta comparación, no se pudo agrupar en el metanálisis ningún ensayo que informaba del volumen de alcohol consumido.
En general, los resultados siguieron siendo consistentes en los análisis de subgrupos separados de las intervenciones universales, selectivas e indicadas. No se informaron efectos adversos.
Conclusiones de los autores
Los resultados de esta revisión indican que no hay beneficios claros de los programas familiares para el consumo de alcohol en los jóvenes. Los modelos difieren levemente entre los resultados, aunque en general, la variación, la heterogeneidad y la cantidad de análisis realizados impiden cualquier conclusión acerca de los efectos de la intervención. Se necesitan estudios independientes adicionales para fortalecer la evidencia y aclarar los efectos marginales observados.
PICO
Resumen en términos sencillos
Prevención familiar del consumo de alcohol en los jóvenes
Pregunta de la revisión
Se examinó la evidencia acerca de los efectos de los programas familiares o de padres para prevenir o reducir el consumo de alcohol en niños en edad escolar.
Antecedentes
El consumo de alcohol expone a los jóvenes a un mayor riesgo de una variedad de efectos perjudiciales a corto y largo plazo y es motivo de preocupación para los servicios sanitarios, los elaboradores de políticas, los trabajadores sociales de la juventud, los profesores y los padres.
Fecha de la búsqueda
La evidencia está actualizada hasta junio de 2018.
Características de los estudios
Se encontraron 46 ensayos controlados aleatorios (estudios en que los participantes fueron asignados al azar a uno de dos o más grupos de intervención o control) que compararon las intervenciones familiares con ninguna intervención o un componente para adolescentes solamente. Se incluyeron estudios orientados a la población general de padres y niños (intervenciones universales), los orientados a los padres de niños en mayor riesgo de consumo de alcohol (intervenciones selectivas) y los estudios orientados a los padres de niños que ya consumen alcohol (intervenciones indicadas). El interés estaba en los estudios que siguieron a los participantes hasta cuatro años después de la intervención.
La mayoría de los estudios se realizaron en los Estados Unidos o en países europeos (Países Bajos, Suecia, Polonia y Alemania). Un estudio se realizó en India. Las intervenciones se implementaron en diversos ámbitos, incluida la escuela o el domicilio familiar y por Internet o con material impreso. Aunque las intervenciones variaron en intensidad, duración y enfoque, todas estaban orientadas al consumo de alcohol u otras drogas mediante la promoción de enfoques de parentalidad positiva o la mejoría de las relaciones entre padres e hijos. Las intervenciones se centraron en la comunicación, la dinámica familiar, la fijación de reglas y el manejo de los riesgos.
El número total de participantes en los estudios incluidos fue de 39 822, y los jóvenes seleccionados tenían entre cinco y 17 años de edad. El origen étnico de los participantes fue mixto: 12 estudios estaban orientados específicamente a grupos de minorías étnicas.
Resultados clave
En general, no se halló evidencia de efectividad de las intervenciones familiares en la prevalencia, la frecuencia ni el volumen de alcohol consumido en los jóvenes. Algunos análisis centrados en subgrupos específicos de estudios (p.ej. los que incluyen sólo intervenciones universales, orientadas a grupos de minorías étnicas) mostraron pequeños efectos de la intervención, aunque según la variación de los resultados, la variación entre los estudios y la baja calidad general de la evidencia, no se sabe si estas intervenciones tienen un efecto positivo sobre el consumo de alcohol en jóvenes. Algunos estudios informaron de efectos positivos de la intervención sobre los resultados secundarios (suministro de alcohol por los padres, participación de la familia, consumo excesivo de alcohol y dependencia del alcohol) aunque las cifras fueron bajas; no se pudieron agrupar estos estudios, por lo que la evidencia es insuficiente. No se informaron efectos adversos.
Calidad de la evidencia
En general, sólo evidencia de calidad muy baja o baja muestra los efectos pequeños hallados en esta revisión. Muchos de los estudios no describieron de forma adecuada cómo las familias, los jóvenes y los padres fueron asignados a los grupos de estudio o cómo ocultaron la asignación a los grupos a los participantes y el personal. Se disminuyó la calidad de la evidencia debido a la heterogeneidad (variabilidad) entre los estudios y la imprecisión (variación) en los resultados. Estos problemas en la calidad del estudio podrían dar lugar a sobreestimaciones de los efectos de la intervención, de manera que no es posible descartar que pudieran ser sobrevalorados los efectos leves observados en esta revisión.
Los National Institutes of Health (NIH) de los EE.UU. y los National Institutes of Alcohol Abuse and Alcoholism (NIAAA), Drug Abuse (NIDA) and Mental Health brindaron el financiamiento para más de la mitad (28/46) de los estudios incluidos en esta revisión. Tres estudios no aportaron información acerca del financiamiento, y sólo 13 artículos declararon un conflicto de intereses evidente.
Conclusiones de los autores
Summary of findings
| Family/parent interventions compared with no intervention/standard care for prevalence of adolescent alcohol consumption | ||||||
| Patient or population: parents/children Settings: recruitment through schools (n = 11), communities (n = 6), paediatric emergency departments (n = 2), other health clinics (n = 2); referral by schools, the justice system, therapists, physicians, or parents (n = 1); street‐based recruitment (n = 1) or random digit dialling (n = 1); and delivery via resources sent home (n = 3); face‐face in schools, homes, or community venues (n = 14); or via the Internet or computer (n = 2) Intervention: parent interventions (positive parenting and communication and counselling sessions) Comparison: no intervention | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | No. of participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| Risk with no intervention | Risk with parent intervention | |||||
| Alcohol use prevalence Up to 4 years post intervention impact of family/parent interventions compared to control on the prevalence of alcohol consumption or drunkenness | Mean prevalence of lifetime alcohol use was 85%a | Mean prevalence of lifetime alcohol use in intervention groups was zero (0.16 lower to 0.16 higher) | 7490 | ⊕⊕⊝⊝ | Scores estimated using a standardised mean difference of 0.00 (95% CI ‐0.08 to 0.08) | |
| Alcohol use frequency Up to 4 years post intervention impact of family/parent interventions compared to control on the frequency of alcohol consumption | Mean number of drinking days in previous 90 days was 2.5c | Mean number of drinking days in intervention groups was 0.16 lower (0.42 lower to 1.1 higher) | 1855 (8 RCTs) | ⊕⊝⊝⊝ | Scores estimated using a standardised mean difference of ‐0.31 (95% CI ‐0.83 to 0.21) | |
| Alcohol use volume Up to 4 years post intervention impact of family/parent interventions compared to control on the volume of alcohol consumption or drunkenness | Mean number of drinks in the last 30 days among control groups was 0.83e | Mean number of drinks in intervention groups was 0.18 lower (0.34 lower to 0.00 higher) | 1825 (5 RCTs) | ⊕⊕⊝⊝ | Scores estimated using a standardised mean difference of ‐0.14 (95% CI ‐0.27 to 0.00) | |
| Adverse events | No studies reported this outcome | |||||
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence. | ||||||
| aWe have used results (mean scores and standard deviation) from Bauman 2002 to illustrate effect sizes in terms of the measures used in that study. This study was chosen for its use of common outcome measures and intervention approach, and low risk of bias. bDowngraded one level due to high or unclear risk of bias ratings in several domains; downgraded one level due to moderate heterogeneity that was explained only in part in subgroup analysis. cWe have used results (mean scores and standard deviation) from Winters 2012 to illustrate effect sizes in terms of the measures used in that study. This study was chosen for its use of common outcome measures and low risk of bias. dDowngraded one level due to high or unclear risk of bias ratings in several domains; downgraded two levels due to high heterogeneity that was not explained in subgroup analysis; downgraded one level due to imprecision of results, with a wide confidence interval (crosses ‐0.5 and crosses zero; therefore the true effect could be either a benefit or a harm). eWe have used results (mean scores and standard deviation) from Mason 2012 to illustrate effect sizes in terms of the measures used in that study. Although this study provides only small numbers and favours the control condition, it was chosen for the availability of mean and standard deviation derived from a common outcome measure and low risk of bias. fDowngraded one level due to high or unclear risk of bias ratings in several domains; downgraded one level due to a high probability of selective reporting bias, with the meta‐analysis potentially not representative of available studies (only 5 out 9 included studies were included in meta‐analysis). | ||||||
| Family/parent and adolescent interventions compared with adolescent only interventions for adolescent alcohol consumption | ||||||
| Patient or population: parents and children Settings: recruitment through schools (n = 5), community agencies (n = 2), or trauma centres (n = 1), and delivery via resources sent home (n = 3), or face‐face in schools, homes, or community venues (n = 5) Intervention: interventions involving both family/parent components and adolescent components delivered together or separately Comparison: interventions delivered to adolescents only with no family/parent component | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | No. of participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| Risk with adolescent interventions | Risk with addition of parent to adolescent interventions | |||||
| Alcohol use prevalence Up to 4 years post intervention impact of family/parent interventions compared to control on the prevalence of alcohol consumption or drunkenness | Mean prevalence of ever having had an alcoholic drink was 12.9%a | Mean prevalence of ever having had an alcoholic drink in the intervention groups was 0.27 lower (0.62 lower to 0.10 higher) | 5640 | ⊕⊝⊝⊝ | Scores estimated using a standardised mean difference of ‐0.39 (95% CI ‐0.91 to 0.14) | |
| Alcohol use frequency Up to 4 years post intervention impact of family/parent interventions compared to control on the frequency of alcohol consumption | Mean frequency of alcohol use in the previous 30 days was 1 dayc | Mean frequency of alcohol use in the intervention groups was 0.04 lower (0.09 lower to 0.02 higher) | 915 (4 RCTs) | ⊕⊝⊝⊝ | Scores estimated using a standardised mean difference of ‐0.16 (95% CI ‐0.42 to 0.09) | |
| Adverse events | No studies reported this outcome | |||||
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence. | ||||||
| aWe have used results (mean scores and standard deviation 0.68) from Reddy 2002 to illustrate effect sizes in terms of the measures used in that study. This study was chosen for its use of a common outcome measure and low risk of bias. bDowngraded one level due to high or unclear risk of bias ratings in several domains; downgraded two levels due to high heterogeneity that was not explained in subgroup analysis; downgraded one level due to imprecision of results, with a wide confidence interval (crosses ‐0.5 and crosses zero; therefore the true effect could be either a benefit or a harm). cWe have used results (mean scores and standard deviation) from Schinke 2004 to illustrate effect sizes in terms of the measures used in that study. This study was chosen for its use of a common outcome measure and low risk of bias. dDowngraded one level due to high or unclear risk of bias ratings in several domains; downgraded one level due to moderate heterogeneity that was explained only in part in subgroup analysis; downgraded one level due to imprecision of results, with a wide confidence interval (crosses ‐0.5 and crosses zero; therefore the true effect could be either a benefit or a harm) and a relatively small sample size. | ||||||
Antecedentes
Descripción de la afección
El consumo de alcohol se clasifica entre los tres factores de riesgo más altos de la carga global de morbilidad y representa un 5,5% de los años de vida ajustados por discapacidad (AVAD) a nivel global (Lim 2012). Se ha establecido una relación causal entre el alcohol y más de 200 enfermedades crónicas y agudas, así como lesiones intencionales y no intencionales (Rehm 2010). En general, en 2010 las lesiones atribuibles al alcohol fueron responsables de un 13,2% de todas las muertes por lesión y un 12,6% de todos los años de vida potenciales perdidos (AVPP) por lesiones (Rehm 2013). Los jóvenes contribuyen con una proporción alta de las lesiones y la mortalidad relacionadas con el alcohol por lesiones atribuibles al alcohol y un 11% de las muertes entre los hombres de 15 a 34 años de edad, y un 3,5% de las muertes entre las mujeres de 15 a 34 años de edad en la Unión Europea se relacionan con el alcohol (Rehm 2012). En la Unión Europea, los accidentes de tránsito son la causa principal de muerte en niños y adultos jóvenes de hasta 29 años, y un 33% de las lesiones causadas por accidentes de tránsito con vehículos motorizados a los hombres y un 11% a las mujeres de todas las edades se deben al alcohol (WHO 2012). La evidencia exhaustiva señala una asociación entre el inicio en el consumo de alcohol a edad temprana (y la intoxicación precoz) y el aumento de la frecuencia, así como un aumento del consumo riesgoso de alcohol y de los daños relacionados con el alcohol en la adolescencia y durante la adultez (p.ej. Bonomo 2004; DeWit 2000; Jackson 2015; Kuntsche 2013; Livingston 2008; Waller 2018).
La experimentación con conductas peligrosas comienza habitualmente en la adolescencia, como parte de un proceso natural de "alcanzar la mayoría de edad" (Room 2004). Se observa un aumento notable del consumo de alcohol después de los 12 años de edad, con tasas que aumentan de manera gradual a través de toda la adolescencia (Currie 2012). Este modelo es frecuente a nivel mundial; los informes de 43 países incluidos en el Health Behaviour in School‐Aged Children Project (Currie 2012), los informes del European Survey Project on Alcohol and Drugs (ESPAD; Hibell 2012), y los resultados de las encuestas nacionales realizadas en Australia ‐ White 2012 ‐ y los Estados Unidos (EE.UU.) ‐ Frieden 2014 ‐ demuestran estos modelos. Cualquier nivel del consumo de alcohol es potencialmente perjudicial para los jóvenes y se observa evidencia de un efecto sobre el cerebro en desarrollo (Bava 2010), junto con un aumento posterior del riesgo de trastornos por consumo alcohol (Waller 2018). El hecho de beber alcohol en sorbos de forma temprana se ha asociado con mayores probabilidades de consumo de bebidas completas, embriaguez y consumo excesivo luego en la adolescencia (Jackson 2015). El consumo de al menos una bebida estándar de alcohol a los 13 años de edad o antes se ha asociado con un mayor riesgo de consumo compulsivo frecuente en la etapa posterior de la escuela secundaria (Aiken 2018). Incluso una única ocasión de intoxicación por alcohol puede tener consecuencias graves a corto y a largo plazo (Courtney 2009; Quinn 2011). En el ámbito internacional, las guías para el consumo de alcohol de bajo riesgo recomiendan a los jóvenes (en Australia menores de 18 años de edad y en los EE.UU. menores de 21) que no beban en absoluto (NHMRC 2009; USDHHS 2015).
Aunque el consumo de alcohol es frecuente entre los jóvenes, algunos grupos pueden identificarse como en riesgo elevado de consumo intenso debido a un rango de factores sociales, de compañeros y familiares. Livingston y colegas informan que los jóvenes que han consumido la primera bebida alrededor de los 13 años de edad tienen casi dos veces más probabilidades de involucrarse en el consumo de alcohol de muy alto riesgo a la edad de 16 a 24 (Livingston 2008). Los padres que les permiten a sus hijos consumir alcohol en ámbitos supervisados por adultos en la adolescencia temprana tienen mayor probabilidad de tener niños que experimentan consecuencias perjudiciales del alcohol en la etapa media de la adolescencia (McMorris 2011). Además, es más probable que los padres que beben en exceso tengan niños que informan de ocasiones de consumo de alcohol excesivo (Hingson 2014), y en estudios longitudinales se ha identificado el consumo de sustancias por los padres y unos antecedentes familiares de alcoholismo como variables predictivas de consumo de sustancias por los adolescentes (Alati 2014; Chassin 1996; Cranford 2010; White 2000; Wills 2003). Hay evidencia conflictiva con relación a la asociación entre la desventaja socioeconómica y el riesgo de consumo de alcohol en los adolescentes (Hanson 2007). Algunos informes revelan que el consumo y la embriaguez se asociaron con niveles inferiores de desventajas o niveles más altos de ingresos familiares (Reboussin 2010; Richter 2009). Otros informes indican niveles más altos de problemas con el alcohol al inicio en las comunidades de bajo nivel socioeconómico (Caria 2011; Lowry 1996).
Descripción de la intervención
A pesar de la influencia de los compañeros y la sociedad durante la adolescencia (Carter 2007; Patton 2004), el ambiente doméstico y la parentalidad son factores influyentes significativos del desarrollo (Steinberg 2001), así como variables predictivas del consumo de alcohol y consumo de otras sustancias (Carter 2007; Simons‐Morton 2009; Turrisi 2010; Wang 2009). Se informa que el conocimiento materno y paterno de los amigos y del paradero del niño actúa como un factor protector contra el consumo de sustancias y para mediar la variabilidad en el consumo de sustancias por grado y origen étnico (Wang 2009). Se sugiere que este efecto protector actúa a través de una influencia en la selección del grupos de compañeros (Engels 2007; Wang 2009), la transmisión de las actitudes y valores familiares (White 2010), y la vigilancia parental (conocimiento del paradero del niño) (Jimenez‐Iglesias 2013).
En 1994 los Institutes of Medicine de los EE.UU. adoptaron un marco para la clasificación de la salud mental y las intervenciones de prevención del consumo de sustancias como universales, selectivas, o indicadas/orientadas (Mrazek 1994; Springer 2006). Las estrategias de prevención universales se dirigen a toda la población dentro de un contexto particular. Las intervenciones selectivas se administran a subgrupos de individuos sobre la base de su incorporación en un grupo que tiene un riesgo elevado de desarrollo de problemas. Las intervenciones indicadas están orientadas a los individuos vulnerables y los ayudan a tratar y afrontar los rasgos de personalidad que los hacen más vulnerables al aumento del consumo de drogas (EMCDDA 2015).
Aunque los programas de intervención por lo general se clasifican como pertenecientes a uno de estos tres grupos amplios, la clasificación puede considerarse un proceso continuo, con una superposición obvia entre los grupos. En el informe de 2010 "Fair Society, Healthy Lives", comisionado por el gobierno del Reino Unido (Reino Unido) para identificar las estrategias más basadas en evidencia para reducir las desigualdades de salud, una recomendación clave fue extender el foco de las actividades preventivas más allá del más desfavorecido, para abarcar el espectro total del gradiente social. Se declaró que para "reducir la inclinación del gradiente social en la salud, las acciones deben ser universales, aunque con una escala e intensidad que es proporcional al nivel de la desventaja" (Marmot 2010).
Aplicado a los esfuerzos de prevención del consumo de alcohol, este “universalismo proporcional” puede interpretarse como la necesidad de realizar programas de prevención universales, aunque también de incluir intervenciones más orientadas (selectivas e indicadas) para grupos de mayor riesgo. Las aptitudes de parentalidad se reconocen como un factor clave en la prevención del consumo de alcohol en adolescentes y otro consumo de sustancias. El enfoque del universalismo proporcional mantiene que a todos los padres se les deben ofrecer oportunidades de apoyo y ayuda para desarrollar aptitudes de parentalidad protectora apropiadas, y que a algunos padres que demuestran un perfil de riesgo particular o que tienen necesidades particulares (p.ej. tienen niños vulnerables) se les debe ofrecer intervenciones cada vez más orientadas (y cada vez más costosas) (Heginbotham 2012; Marmot 2010). Por este motivo, esta revisión no está limitada a las intervenciones universales, aunque incorporará las clasificadas como selectivas e indicadas.
La clasificación de las intervenciones en la presente revisión se basa en la población destinataria, ya sea que se basaran en todos los padres (universales) o en un grupo selecto según las características de los padres o los niños (selectivos e indicados). En el contexto de las intervenciones familiares para el consumo de alcohol en los jóvenes, las intervenciones universales son orientadas a los padres de todos los niños debido al riesgo inherente del consumo de alcohol entre todos los sectores de la población. Probablemente estas intervenciones buscarán retrasar el inicio del consumo de alcohol o reducir la frecuencia o el volumen de consumo en los hijos de los padres participantes. Las intervenciones selectivas son las orientadas a los padres cuyos niños tienen un riesgo elevado de consumo de sustancias debido a factores de riesgo sociales o familiares. Dichos factores de riesgo incluyen un nivel socioeconómico o ingresos familiares bajos, junto con el consumo de alcohol, el alcoholismo, u otro consumo de sustancias por parte de los padres. De manera similar, estas intervenciones probablemente procurarán retrasar la iniciación o reducir el consumo. Las intervenciones indicadas se definen como las que se orientan a los padres o las familias cuyos niños ya son identificados como bebedores. Estas intervenciones más probablemente procurarán reducir los niveles del consumo o la frecuencia del consumo compulsivo o reducir los daños relacionados con el alcohol.
Los programas de padres y familiares para la prevención del consumo de alcohol a menudo se adjuntan a las intervenciones escolares basadas en los programas de estudios para los jóvenes, aunque también pueden estar diseñados como programas independientes. Estos programas se centran con frecuencia en la comunicación entre padres e hijos y la construcción de relaciones. Los elementos comunes a través de muchos programas incluyen un énfasis en las aptitudes de competencia social, el compromiso de los padres con los niños, y la autorregulación, aunque la población destinataria y la intensidad y la modalidad de la administración varían enormemente.
De qué manera podría funcionar la intervención
La base teórica para las intervenciones familiares es que los jóvenes cuyos padres adoptan estrategias apropiadas de parentalidad probablemente desarrollan normas sociales positivas y resisten las influencias externas negativas de los compañeros y la sociedad. En este contexto, las estrategias de parentalidad positiva incluyen la fijación de reglas, la comunicación apropiada, la vigilancia y la transmisión de valores y actitudes positivas (Ryan 2010). Las intervenciones familiares y de padres para el consumo de sustancias en adolescentes operan indirectamente y el mecanismo del efecto funciona a través de los padres en lugar de mediante un programa administrado directamente a los jóvenes como la población destinataria. Como tal, la trayectoria del desarrollo de los comportamientos particulares, p.ej. el consumo de alcohol, cambia a través de la mejoría en las prácticas de socialización familiares o de los padres (Foxcroft 2014).
Por qué es importante realizar esta revisión
Las revisiones Cochrane anteriores han tratado por separado los programas familiares universales (Foxcroft 2011a), así como las intervenciones escolares y multicomponente (Foxcroft 2011b; Foxcroft 2011c, respectivamente), para el abuso de alcohol en los jóvenes que incorporan intervenciones familiares. La más reciente de estas revisiones se completó con estudios publicados hasta julio de 2010. Desde el momento en que se realizó dicha revisión, se han publicado varios ensayos que informan de otros programas preventivos familiares y que en muchos casos utilizan enfoques innovadores incluida la entrega en línea.
Además de la actualización de la revisión anterior (Foxcroft 2011a), la revisión actual se extiende más allá de las intervenciones universales para incluir las clasificadas como selectivas e indicadas, de acuerdo con el concepto del universalismo proporcional.
Aunque los padres y las familias son influyentes y proporcionan una meta clave para la intervención, los programas familiares suelen ser costosos y desafiantes desde la perspectiva del reclutamiento y la participación (Haggerty 2006). Es importante obtener evidencia de su efectividad, y de la efectividad diferencial de diversos componentes de estos programas, para informar la política y las decisiones de financiamiento.
Objetivos
Evaluar la efectividad de los programas de prevención familiares universales, selectivos e indicados para prevenir el consumo de alcohol o los problemas con el alcohol en los niños de edad escolar (hasta 18 años de edad).
Específicamente, en cuanto a estos resultados, la revisión buscó:
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evaluar la efectividad de los programas de prevención familiares universales para todos los niños hasta los 18 años ("intervenciones universales");
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evaluar la efectividad de los programas de prevención familiares selectivos para niños de hasta 18 años de edad en riesgo elevado de consumo de alcohol o problemas con el alcohol ("intervenciones selectivas"); y
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evaluar la efectividad de los programas de prevención familiares indicados para niños de hasta 18 años de edad que actualmente consumen alcohol o han iniciado el consumo o el consumo habitual ("intervenciones indicadas").
Métodos
Criterios de inclusión de estudios para esta revisión
Tipos de estudios
Ensayos controlados aleatorios (ECA), incluidos los ensayos asignados al azar por grupos.
Tipos de participantes
Los padres o tutores/cuidadores de jóvenes de hasta 18 años (de edad escolar). Para esta revisión, se definió a los jóvenes como niños y adolescentes y se excluyó a los que ingresaban a la universidad debido a las diferencias en el contexto y las funciones de parentalidad. Se incluyó a padres de jóvenes que no han consumido alcohol previamente, que actualmente consumen alcohol o que presentan un consumo de alcohol intenso o problemático. Los jóvenes también estuvieron incluidos como participantes en algunas intervenciones y en el contexto de la obtención de datos.
Tipos de intervenciones
Cualquier intervención de prevención familiar universal, selectiva, o indicada, psicosocial o educacional.
Las estrategias de prevención universales se definieron como las dirigidas a toda la población sin selección de los niños basado en las características que pueden aumentar el riesgo del consumo de alcohol o los problemas con el alcohol, p.ej. las ofrecidas a todos los padres de los niños que asisten a la escuela.
Las intervenciones selectivas se definieron como las implementadas en un subgrupo de niños en quienes se identificaron características sociodemográficas o de otro tipo, y que los colocan en un mayor riesgo de consumo de alcohol o problemas con la bebida, por ejemplo, las intervenciones implementadas en familias en que hay antecedentes de consumo de sustancias o problemas de salud mental en los padres, en los individuos que viven en comunidades de nivel socioeconómico bajo o en los que cometen delitos.
Las intervenciones indicadas se definieron como las dirigidas a un subgrupo de niños que actualmente consumen alcohol o que pueden tener problemas relacionados con el alcohol.
Se incluyeron programas de prevención centrados en el alcohol así como otras drogas siempre que los resultados relacionados con el alcohol se presentaran por separado. Las intervenciones psicosociales se definieron como intervenciones que procuran específicamente desarrollar atributos y aptitudes psicológicas y sociales en los padres o los jóvenes (p.ej. vigilancia parental, normas conductuales, resistencia a los compañeros), para que los jóvenes tengan una menor probabilidad de consumir alcohol. Las intervenciones educativas se definieron como las que procuran específicamente aumentar la conciencia entre los padres o los cuidadores sobre cómo influir de manera positiva en los jóvenes, o de los riesgos del consumo de alcohol, para que los jóvenes tengan una menor probabilidad de consumir alcohol.
La comparación constó de cualquier programa de prevención alternativo (p.ej. basado en la escuela, basado en la oficina, multicomponente, otro) en el que el componente parental podría ser experimentalmente aislado (p.ej. progenitor más escuela en comparación con escuela solamente) o ningún programa.
Tipos de medida de resultado
Resultados primarios
Cualquier medida directa autoinformada (por los adolescentes) del consumo de alcohol o los problemas con el alcohol. Como ejemplo, se consideró que los siguientes resultados fueron relevantes.
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Consumo de alcohol (sí / no).
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Consumo de alcohol (cantidad, frecuencia).
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Consumo ocasional en grandes cantidades (p.ej. definido como beber cinco o más tragos en una ocasión) (sí / no).
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Incidencia de embriaguez.
Se consideró que las medidas de resultado relacionadas con la percepción psicológica/actitudes o la conciencia sobre los riesgos del alcohol eran indirectas; por lo tanto no se las consideró en esta revisión.
Resultados secundarios
Los resultados secundarios podían medirse a través del autoinforme (por parte de los adolescentes o los padres) o a través de la policía, la justicia de menores, o las historias clínicas.
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Edad de inicio del consumo de alcohol.
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Edad de la iniciación de la embriaguez.
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Los problemas o los daños relacionados con el alcohol (p.ej. manejar bajo la influencia del alcohol o cualquier problema físico o social autoinformado por los adolescentes como una consecuencia relacionada con el alcohol puede medirse con una escala como Rutgers Alcohol Problems Index o las preguntas 7 a 10 del Alcohol Use Disorders Identification Test [AUDIT]).
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Comportamientos parentales relacionados con el alcohol informados por los padres o informados por el niño (p.ej. suministro de alcohol, comunicación específica sobre el alcohol, fijación de reglas específicas del alcohol).
Métodos de búsqueda para la identificación de los estudios
Búsquedas electrónicas
We searched the following databases, without restrictions by language or publication status, in June 2018. The search strategy is based on that used by Foxcroft 2011a but with the removal of terms that were designed to limit the previous review to universal interventions. Thus these searches were conducted afresh from the earliest available records with no limits placed on publication date.
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Cochrane Drugs and Alcohol Group's Specialised Register of Trials.
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Cochrane Central Register of Controlled Trials (CENTRAL, 2018 issue), in the Cochrane Library.
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MEDLINE (Ovid) (1966 to 30 June 2018).
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Embase (Embase.com) (1974 to 30 June 2018).
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Education Resource Information Center (ERIC; EBSCOhost) (1966 to 30 June 2018)
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PsycINFO (Ovid) (1806 to 30 June 2018).
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Google Scholar (modified MEDLINE search to account for 260 character limit).
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Project CORK (http://www.projectcork.org).
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ClinicalTrials.gov (clinicaltrials.gov/).
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International Clinical Trials Registry Platform (ICTRP) (apps.who.int/trialsearch/).
The subject strategies for databases were modelled on the search strategy designed for CENTRAL. Where appropriate, these were combined with subject strategy adaptations of the Cochrane highly sensitive search strategy for identifying RCTs and controlled clinical trials (as described in the Cochrane Handbook for Systematic Reviews of Interventions, Version 5.1.0, Box 6.4.b; Higgins 2011). Search strategies for major databases are provided in Appendix 1.
Búsqueda de otros recursos
We handsearched the reference lists of topic‐related systematic reviews and included studies to identify potentially relevant citations (Dusendury 2000; Gates 2006; Hale 2014; Kuntsche 2016; Lemstra 2010; MacArthur 2012; Petrie 2007 Smit 2008; Vermeulen‐Smit 2015; ). Unpublished reports, abstracts, dissertations, and brief and preliminary reports were eligible for inclusion.
Obtención y análisis de los datos
Selección de los estudios
Pairs of independent reviewers (including CG, AW, LW, JT, TS, ES) completed broad screening of titles and abstracts of all identified records (screening level 1). Afterwards, the same pairs independently assessed full‐text reports of all potentially relevant records that passed the initial screen. We resolved differences in opinion arising at both screening levels through discussion and involvement of a third review author for resolution where required. Reasons for exclusion of full‐text articles were recorded and are reported in Characteristics of excluded studies.
Extracción y manejo de los datos
Pairs of review authors independently extracted relevant data using an a priori defined data extraction form (CG, AW, ES, TS), and one review author (AW) entered data into Review Manager 5 software (RevMan 2014). We resolved differences in opinion arising during data extraction through discussion and involvement of a third review author for resolution where required. We extracted the following information: numbers and characteristics of participants, setting, types of experimental and control interventions, length of follow‐up, types of outcomes, outcome data (sample sizes, means, standard deviations, odds ratios, confidence intervals as available), country of origin, and methodological characteristics associated with the assessment of risk of bias (randomisation procedures, blinding, data collection procedures, attrition, outcome reporting, and analysis characteristics associated with clustered studies).
Evaluación del riesgo de sesgo de los estudios incluidos
For each study included in the review, two review authors independently assessed the risk of bias (CG, AW, TS, ES, MK). We performed the risk of bias assessment for RCTs in this review using the criteria recommended in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). The recommended approach addresses seven specific domains, namely, sequence generation and allocation concealment (selection bias), blinding of participants and providers (performance bias), blinding of outcome assessor (detection bias), incomplete outcome data (attrition bias; less than 20% loss of participants with no differential attrition between experiment groups was regarded as low risk), selective outcome reporting (reporting bias), and other sources of bias (contamination bias). For C‐RCTs, we also assessed risk of recruitment bias, baseline imbalances, loss of clusters, incorrect analysis, and compatibility with individually randomised trials (herd effect). The first part of the tool involves describing what was reported to have happened in the study. The second part of the tool involves assigning a judgement related to the risk of bias for that entry, in terms of low, high, or unclear risk. To make these judgements, we used the criteria indicated by the Cochrane Handbook for Systematic Reviews of Interventions, as adapted to the addiction field. See Appendix 2 for details.
Grading of evidence
We assessed the overall quality of the evidence for the primary outcome of each study using the GRADE system. The Grading of Recommendation, Assessment, Development and Evaluation Working Group (GRADE) developed a system for grading the quality of evidence (GRADE 2004; Guyatt 2008; Guyatt 2011), which takes into account issues related not only to internal validity (risk of bias) but also to external validity, such as directness, consistency, imprecision of results, and publication bias. The 'Summary of findings' tables present the main findings of a review in a transparent and simple tabular format. In particular, they provide key information concerning the quality of evidence, the magnitude of effect of the interventions examined, and the sum of available data on the main outcomes.
In this review, we present the 'Summary of findings' tables based on type of intervention programme (universal, selective, indicated) and type of comparison (intervention vs intervention as well as comparative effectiveness trials). Summary tables cover those comparisons where sufficient studies were available to enable meta‐analytical pooling.
The GRADE system uses the following criteria in assigning grades of evidence.
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High: we are very confident that the true effect lies close to that of the estimate of the effect.
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Moderate: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
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Low: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
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Very low: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
Comparisons of RCTs begin with a 'high' rating and are downgraded based on serious (‐1) or very serious (‐2) limitation to study quality; important inconsistency (‐1); some (‐1) or major (‐2) uncertainty about directness; imprecise or sparse data (‐1); and high probability of reporting bias (‐1).
Medidas del efecto del tratamiento
We calculated treatment effects using RevMan 2014 where possible.
Dichotomous outcome data
We analysed dichotomous outcomes by calculating the risk ratio (RR) for each trial, with the uncertainty in each result expressed using 95% confidence intervals (CIs).
Continuous outcome data
We analysed continuous outcomes by calculating mean differences (MDs) if all studies used the same measurement scale, or standardised mean differences (SMDs) if studies used different measurement scales, each with 95% CIs. If data in small studies were skewed, we assessed the implications for outcomes on a case‐by‐case basis.
Cuestiones relativas a la unidad de análisis
We ascertained additional validity threats regarding appropriate unit of analysis depending on whether randomisation was implemented at an individual or cluster level. We assessed cluster‐randomised trials in the review for unit of analysis error. For studies that did not adjust for clustering, we calculated design effects and effective sample sizes using available study data and reported intraclass correlations (ICCs). Where ICCs were not available, we used a mean ICC calculated from reported ICCs of included studies to calculate effective sample sizes before inclusion in meta‐analysis (Higgins 2011). We included studies with more than two trial arms in the meta‐analysis by selecting the most appropriate intervention and comparison (e.g. family‐based intervention vs no‐intervention control, with no data taken from a classroom‐based intervention arm). We included studies in two separate meta‐analyses if they included a family‐based intervention arm that could be compared separately with a no‐intervention or standard care arm and a family and adolescent intervention.
Manejo de los datos faltantes
Where important summary data or study level characteristics were missing, we attempted to contact the authors of those included studies. Where standard deviations were missing from continuous data, we scanned studies for any other statistics (CIs, standard errors, T values, P values, F values) that allowed for their calculation. Where available, we reported outcomes of trials reporting an intention‐to‐treat analysis.
Evaluación de la heterogeneidad
Assessment of heterogeneity involved inspecting each included study for variability in study populations (baseline characteristics), interventions (target/focus, mode of delivery), and outcome measures (tools, instruments, scales, and outcome definitions). We considered methodological heterogeneity by inspecting variability in study design and risk of bias. Where acceptable homogeneity was found within subgroups (based on age of children, type of intervention, or substance targeted), we conducted meta‐analysis for subgroups of studies. We assessed statistical heterogeneity using the Chi² test and its P value, by visually inspecting the forest plots, and by using the I² statistic. A P value of the test lower than 0.10 or an I² statistic of at least 50% indicated significant statistical heterogeneity.
Evaluación de los sesgos de notificación
We used funnel plots (plots of the effect estimate from each study against the sample size or effect standard error) to indicate possible publication bias. We used tests for funnel plot asymmetry only when a minimum of 10 studies were included in the meta‐analysis, as fewer than 10 studies would render the power of the tests too low to distinguish chance from real asymmetry.
Síntesis de los datos
We calculated pooled standardised mean differences (to account for heterogeneity of outcome measures) for each comparison using a random‐effects model with a generic inverse variance weighting method (RevMan 2014). We calculated standardised mean differences for all outcome measures to maximise comparability, and we used the generic inverse variance method, which allows for inclusion of studies reporting data in a range of forms including both continuous and dichotomous outcomes along with those reporting odds ratios, risk ratios, or differences between means. We selected post‐intervention values over changes from baseline data for inclusion in the meta‐analysis, to reduce the risk of selective reporting and to maximise the number of studies that could be pooled.
We synthesised studies that provided suitable data for pooling in meta‐analysis grouped by outcome. Due to small numbers of studies in each comparison, we explored effects by type of prevention intervention (i.e. universal, selective, or indicated) in subgroup analyses. Depending on study numbers in each comparison, selective and indicated interventions may be grouped together to represent more targeted approaches in contrast to universal ones; these would be regarded as further along the scale of proportionate universalism (Marmot 2010). We grouped outcomes as measuring alcohol use prevalence (measures of the prevalence of any alcohol consumption or a specified threshold of consumption such as the prevalence of drinking at least once per month); frequency (measures of the number of occasions of use in a given period); or volume (measures of the number of drinks in a given period). When studies reported multiple alcohol outcomes in one of these categories, we selected the most conservative measure capturing small or infrequent levels of use (e.g. the frequency of any drinking was selected in preference to the frequency of drunkenness, if both were available). Studies could contribute to multiple meta‐analyses if they reported eligible outcomes in more than one category. From studies that reported multiple follow‐up points, we extracted data from the longest follow‐up period up to four years for inclusion in meta‐analyses.
We selected study estimates that adjusted for potential confounding variables for inclusion in meta‐analysis over estimates that did not adjust for potential confounding variables, when available. Similarly, we selected C‐RCT study estimates that were adjusted for clustering for inclusion in meta‐analyses over unadjusted estimates. For those C‐RCTs that did not adjust for clustering, we adjusted study estimates using a mean ICC from other included studies and the effective sample size used in meta‐analysis. We pooled separately studies that compared two or more alternative interventions, enabling experimental isolation of the parent intervention component.
In all instances where data could not be pooled in a meta‐analysis, we have provided a narrative summary of the trial findings according to the review objectives.
Análisis de subgrupos e investigación de la heterogeneidad
We investigated the extent of heterogeneity through visual examination of forest plots and through use of the Chi² statistic, the P value, and the I² statistic. Where there was evidence of heterogeneity (I² statistic > 50%), we investigated the potential source of heterogeneity through subgroup analyses. Specifically, we conducted subgroup analyses based on the type of prevention intervention (universal, selective, indicated), the intensity of the intervention (considering duration and level of face‐to‐face involvement), the characteristics of participants (ethnicity and gender), and the length of follow‐up (less than 12 months, or between 12 months and 4 years).
Análisis de sensibilidad
We performed sensitivity analysis of the main review outcomes, removing trials judged to be at high risk of bias (graded as high on three or more 'Risk of bias' measures). For C‐RCTs, two or more ratings of high risk on any of the five cluster‐specific risk of bias domains contributed one high risk rating to the overall assessment.
Results
Description of studies
See Characteristics of included studies,Characteristics of excluded studies, and Characteristics of ongoing studies.
Results of the search
See the CONSORT flow diagram (Figure 1).
Study flow diagram.
The search strategy resulted in a total of 23,367 citations, and we identified a further 11 studies by checking the reference lists of relevant systematic reviews. After removal of duplicate records, 13,399 records remained. Screening of titles and abstracts revealed 184 studies for full‐text review and formal inclusion or exclusion. Of these, 46 papers met the inclusion criteria as primary studies (Arnaud 2016; Baldus 2016; Bauman 2002; Bodin 2011; Brody 2006; Catalano 1999; Cordova 2012; Dembo 2001; Estrada 2017; Fang 2010; Fosco 2013; Foxcroft 2017; Furr‐Holden 2004; Haggerty 2007; Koning 2009; Liddle 2008; Linakis 2013; Loveland‐Cherry 1999; Mares 2016; Mason 2012; Milburn 2012; O'Donnell 2010; Perry 2003; Prado 2012; Reddy 2002; Riesch 2012; Schinke 2004; Schinke 2009a; Schinke 2009b; Schinke 2009c; Schinke 2011; Skarstrand 2014; Spirito 2011; Spirito 2015; Spirito 2017; Spoth 1999a; Spoth 2002; Stanger 2017; Stevens 2002; Stormshak 2011; Valdez 2013; Werch 2008; Winters 2012; Wolchik 2002; Wu 2003; Wurdak 2017), and a further 31 as companion papers to included trials.
Included studies
A description of the included studies appears in the Characteristics of included studies tables. We included 46 studies with 39,822 participants (or families) randomised across the 46 included trials. Thirty‐one studies were RCTs, 25 of which compared an intervention group versus a no intervention control group or a 'usual care' group (Baldus 2016; Bauman 2002; Catalano 1999; Cordova 2012; Dembo 2001; Estrada 2017; Fang 2010; Fosco 2013; Haggerty 2007; Linakis 2013; Loveland‐Cherry 1999; Mason 2012; Milburn 2012; O'Donnell 2010; Prado 2012; Schinke 2009a; Schinke 2009b; Schinke 2009c; Schinke 2011; Spirito 2017; Stanger 2017; Stormshak 2011; Valdez 2013; Wolchik 2002; Wurdak 2017), and six of which compared the effectiveness of two different family‐ or parent‐focused interventions (Liddle 2008; Schinke 2004; Spirito 2011; Spirito 2015; Werch 2008; Winters 2012). The other 15 included studies were C‐RCTs, 10 of which compared an intervention group versus a no intervention control group (Arnaud 2016; Bodin 2011; Brody 2006; Foxcroft 2017; Furr‐Holden 2004; Koning 2009; Mares 2016; Riesch 2012; Skarstrand 2014; Spoth 1999a), and five of which were comparative effectiveness trials (Perry 2003; Reddy 2002; Spoth 2002; Stevens 2002; Wu 2003). In total, we classified 12 studies as comparative effectiveness trials, usually with more than two trial arms, including a comparison of a family/parent intervention coupled with adolescent intervention components versus the adolescent components alone. In such studies, experimental isolation of the parent component for analysis purposes was possible (Koning 2009; Liddle 2008; Perry 2003; Reddy 2002; Schinke 2004; Spirito 2011; Spirito 2015; Spoth 2002; Stevens 2002; Werch 2008; Winters 2012; Wu 2003).
Twenty‐seven of the included studies tested the impact of interventions classified as universal, targeting all children or families; 12 were selective, targeting groups at elevated risk; and seven were classified as indicated, targeting families where young people were already using alcohol. Of studies comparing universal interventions, 13 were C‐RCTs, with nine using schools as the unit of randomisation, one using county (Brody 2006), one using communities (Foxcroft 2017), one using classrooms (Furr‐Holden 2004), and one using paediatric clinics (Stevens 2002). Among selective and indicated interventions, only one study in each category was a C‐RCT, with the selective study randomising community centres (Wu 2003), and the indicated study randomising paediatric emergency departments (Arnaud 2016). The 14 universal RCTs randomised participants at the level of adolescent‐parent dyads (n = 7; Bauman 2002; Estrada 2017; Linakis 2013; Schinke 2009a; Schinke 2009b; Schinke 2009c; Schinke 2011), families (n = 4; Fosco 2013; Haggerty 2007; Loveland‐Cherry 1999; O'Donnell 2010), adolescents (n = 1; Werch 2008), communities (n = 1; Schinke 2004), or parents (n = 1; Wurdak 2017). The selective RCTs randomised individual families (n = 7; Catalano 1999; Mason 2012; Milburn 2012; Prado 2012; Spirito 2015; Stormshak 2011; Wolchik 2002), adolescents (n = 2; Cordova 2012; Dembo 2001), or dyads (n = 2; Baldus 2016; Fang 2010). The six indicated RCTs randomised at the level of the family (n = 3; Spirito 2011; Spirito 2017; Valdez 2013), or at the level of the adolescent (n = 3; Liddle 2008; Stanger 2017; Winters 2012).
Country
Twenty‐nine trials were undertaken in the United States; 16 studies examined universal interventions (Estrada 2017; Haggerty 2007; Linakis 2013; Loveland‐Cherry 1999; O'Donnell 2010; Schinke 2004; Schinke 2009a; Schinke 2009b; Schinke 2009c; Schinke 2011; Werch 2008; Perry 2003; Riesch 2012; Spoth 1999a; Spoth 2002; Stevens 2002), 11 studies selective interventions (Catalano 1999; Cordova 2012; Dembo 2001; Fang 2010; Mason 2012; Milburn 2012; Prado 2012; Spirito 2015; Stormshak 2011; Wolchik 2002;Wu 2003), and six studies targeted interventions (Liddle 2008; Spirito 2011; Spirito 2017; Stanger 2017; Valdez 2013; Winters 2012). Two trials were conducted in the Netherlands (both universal C‐RCTs; Koning 2009; Mares 2016), two in Sweden (both universal C‐RCTs; Bodin 2011; Skarstrand 2014), one in Poland (a universal C‐RCT; Foxcroft 2017), three in Germany (one universal RCT ‐ Wurdak 2017; one selective RCT ‐ Baldus 2016; and one indicated C‐RCT ‐ Arnaud 2016), and one in India (a universal C‐RCT ‐ Reddy 2002).
Participants
Ethnicity of participants was mixed. Twelve trials included exclusively or over‐represented specific ethnic groups. Four studies exclusively ‐ Wu 2003,Brody 2006 ‐ or predominantly ‐ Furr‐Holden 2004,Liddle 2008 ‐ involved African American participants. Three further studies included a close to 50:50 ratio of African American and Caucasian (or other) participants (Dembo 2001; Haggerty 2007; Riesch 2012). Four studies involved only Hispanic or Mexican American participants (Cordova 2012; Estrada 2017; Prado 2012; Valdez 2013), and one study involved only Asian American participants (Fang 2010). A further 12 studies involved participants from a mix of ethnic backgrounds: two mostly Caucasian and African American (Loveland‐Cherry 1999; Werch 2008); four mostly Causasian and Hispanic/Latino (Mason 2012; Milburn 2012; Spirito 2011; Spirito 2015); and six a mixture of all these groups (O'Donnell 2010; Schinke 2004; Schinke 2009b; Schinke 2009c; Schinke 2011; Stormshak 2011). Twelve studies included a mix of ethnicities but predominantly Caucasian American (Bauman 2002; Catalano 1999; Linakis 2013; Loveland‐Cherry 1999; Perry 2003; Schinke 2009a; Spirito 2017; Spoth 1999a; Spoth 2002; Stanger 2017; Winters 2012; Wolchik 2002). One study involved a broader range of ethnic groups including a minority of Native American and Pacific Islander participants (Fosco 2013). The remaining nine studies did not target particular ethnic groups nor report particular cohort breakdowns.
The age of children targeted through the interventions ranged from 5 to 17 years (average approximately 13 years). Furr‐Holden 2004 involved very young children, with an average age of 6.2 years, and Stanger 2017 involved the oldest cohort, with an average age of 16.1 years. In general, the average age of adolescent participants was higher in trials of selective (approximately 13 years) and indicated (approximately 15.5 years) trials than in trials of universal interventions (approximately 12 years). Six studies exclusively targeted girls, four of which provided universal interventions (O'Donnell 2010; Schinke 2009a; Schinke 2009b; Schinke 2009c), and two of which gave selective interventions (Fang 2010; Schinke 2011).
Recruitment and eligibility
Of the universal interventions, a majority recruited participants via schools (n = 17; Bodin 2011; Brody 2006; Estrada 2017; Fosco 2013; Furr‐Holden 2004; Haggerty 2007; Koning 2009; Loveland‐Cherry 1999; Mares 2016; O'Donnell 2010; Perry 2003; Reddy 2002; Riesch 2012; Skarstrand 2014; Spoth 1999a; Spoth 2002; Werch 2008). Five studies used community advertisements such as newspapers, flyers, and "craigslist" (Schinke 2009a; Schinke 2009b; Schinke 2009c; Schinke 2011; Wurdak 2017); two recruited through community agencies such as after school care and social organisations (Foxcroft 2017; Schinke 2004), one through paediatric emergency departments (Linakis 2013), one through paediatric clinics (Stevens 2002), and one through telephone recruitment (Bauman 2002).
Among the selective interventions, three studies recruited participants specifically from low socioeconomic status or at‐risk areas, with two of these recruiting through schools (Baldus 2016; Stormshak 2011), and one through community organisations and recreation centres (Wu 2003). Four recruited youth who had identified behaviour problems (recruited through schools ‐ Cordova 2012), delinquency (recruited through the juvenile justice system ‐ Dembo 2001; Prado 2012), or emotional or behavioural disorder (referred from mental health clinics, truancy courts, or response to advertisements ‐ Spirito 2015). Three studies targeted children of at risk parents, with one recruiting families through a methadone clinic (Catalano 1999), one recruiting the children of depressed parents through health clinics (Mason 2012), and one recruiting the children of divorced parents identified through court records (Wolchik 2002). One study targeted families with a homeless adolescent recruited through community organisations such as shelters (Milburn 2012). One further study targeted girls from minority ethnic groups identified through community advertisements (Fang 2010).
The seven indicated interventions all involved youth who were already identified as using or abusing alcohol. Two studies recruited participants who attended a paediatric emergency department or trauma centre after an alcohol‐related incident (Arnaud 2016; Spirito 2011), one recruited gang‐affiliated youths via a street‐based outreach approach (Valdez 2013), and one recruited youth who had been identified in a school setting as abusing alcohol and other drugs (Winters 2012). The remaining three studies relied on referrals from truancy courts, schools, juvenile justice, or welfare agencies (Liddle 2008; Spirito 2017; Stanger 2017).
Setting and mode of delivery
Researchers delivered interventions in a range of settings including the child's school, the child's family home, and the Internet or delivered print material. Of the universal interventions, they delivered eight to parents via print materials or audio CD sent by post or via email, or sent home with children (Bauman 2002; Mares 2016; O'Donnell 2010; Perry 2003; Reddy 2002; Schinke 2004; Werch 2008; Wurdak 2017), with one sent by post (n = 1; O'Donnell 2010); four were computer mediated (Schinke 2009a; Schinke 2009b; Schinke 2009c; Schinke 2011); two involved presentations or workshops at the child's school (Bodin 2011; Fosco 2013); and ten involved face‐to‐face sessions, with a combination of group/individual/family sessions delivered at the school or in a community venue (Brody 2006; Estrada 2017; Foxcroft 2017; Furr‐Holden 2004; Haggerty 2007; Koning 2009; Riesch 2012; Skarstrand 2014; Spoth 1999a; Spoth 2002), or at individual parent/family sessions provided in the family home (Loveland‐Cherry 1999), or in a healthcare setting (Linakis 2013; Stevens 2002).
Of the selective interventions, one was delivered via CD‐ROM and Internet (Fang 2010), and ten via face‐to‐face sessions using a combination of group, individual parent, and family approaches (Baldus 2016; Catalano 1999; Cordova 2012; Dembo 2001; Mason 2012; Milburn 2012; Prado 2012; Spirito 2015; Stormshak 2011; Wolchik 2002). Individual parent and family sessions were most commonly delivered in the family home. One study involved face‐to‐face sessions for youth only and a 20‐minute video for parents (Wu 2003). All indicated interventions were delivered through face‐to‐face sessions with parents and youth separately or together, or by a combination of both.
Across all trials, programme intensity varied from six sessions of 20 minutes' duration delivered over three years (Bodin 2011), to twice weekly 90‐minute meetings, a five‐hour retreat, and group workshops occurring over a nine‐month period (Catalano 1999). In general, the selective and indicated interventions were of a consistently higher intensity than the universal ones, with all but one ‐ Fang 2010 ‐ involving at least one face‐to‐face session. Face‐to‐face interventions varied in duration/frequency from a single session in Arnaud 2016 to weekly sessions over periods ranging from five (in Milburn 2012) to 16 weeks (in Valdez 2013) to annual sessions provided over three years (Bodin 2011; Fosco 2013). Interventions delivered by other means also varied, with some spread over four weeks (Wurdak 2017), and others up to six months (Bauman 2002). Duration of follow‐up ranged from immediate post‐test to 15 years post intervention (Wolchik 2002). A small number of trials reported follow‐up beyond four years post randomisation (n = 2; Furr‐Holden 2004; Wolchik 2002); we did not include these trials in the meta‐analysis.
Interventions and comparisons
Although the interventions implemented varied in intensity, duration, and approach, all targeted alcohol or other drug use, and generally did so by promoting positive parenting approaches or by enhancing parent‐child relationships. The interventions focused on elements such as communication, family dynamics, rule‐setting, and risk management. Of the 46 included studies, 23 included a separate youth component in the form of a classroom curriculum or other adolescent‐focused resource (n = 4; Catalano 1999; Perry 2003; Reddy 2002; Schinke 2004), or individual or group youth sessions (and/or involvement in family sessions) as part of face‐to‐face interventions (n = 18; Catalano 1999; Cordova 2012; Dembo 2001; Estrada 2017; Foxcroft 2017; Loveland‐Cherry 1999; Milburn 2012; Prado 2012; Riesch 2012; Skarstrand 2014; Spirito 2011; Spirito 2015; Spoth 2002; Stanger 2017; Stevens 2002; Valdez 2013; Winters 2012; Wolchik 2002).
Universal interventions
Of the universal interventions, eight targeted alcohol specifically (Bodin 2011; Brody 2006; Koning 2009; Loveland‐Cherry 1999; Mares 2016; Schinke 2004; Werch 2008; Wurdak 2017), 12 targeted substance use more generally (Bauman 2002; Foxcroft 2017; Furr‐Holden 2004; Linakis 2013; Riesch 2012; Schinke 2009a; Schinke 2009b; Schinke 2009c; Schinke 2011; Spoth 1999a; Spoth 2002; Stevens 2002), five targeted problem behaviours and substance use (Fosco 2013; Haggerty 2007; Perry 2003; Skarstrand 2014; Estrada 2017), and the remainder targeted alcohol as well as tobacco (Bauman 2002), sexual behaviour (O'Donnell 2010), or tobacco alone (Reddy 2002).
Six universal studies used the original structure or an adaptation of the Strengthening Families Program (SFP), which is based on the Social Development Model and aims to enhance parent and child interactions to reduce risk factors for substance use and substance use initiation (Brody 2006; Foxcroft 2017; Riesch 2012; Skarstrand 2014; Spoth 1999a; Spoth 2002). Investigators in each of these studies ran multiple face‐to‐face sessions over a period of several weeks. Generally in the first hour, parents and adolescents attended separate workshops before coming together for family workshops in the second hour. Workshop sessions were focused on skill‐building and relationship development, using role‐plays and games. The most common model for the Strengthening Families Program consisted of seven sessions over seven weeks and was used in four studies (Brody 2006; Foxcroft 2017; Riesch 2012; Spoth 2002). One study adapted the SFP to include two parts; part 1 included six separate parent and youth sessions and one family session, and part 2 involved four separate sessions and one joint session (Skarstrand 2014). One selective study also used the SFP in its seven‐session format with four booster sessions (Baldus 2016).
One of these studies assessed the SFP as a complement to a 15‐session classroom‐based curriculum of Life Skills Training (LST) for children in grades seven and eight (Spoth 2002), thereby investigating effects of the SFP via a comparative effectiveness approach (one arm was LST only, and the other LST plus SFP). Another study adopted a five‐session model of the SFP, with children only attending one of these sessions, and compared this to the Preparing for Drug Free Years (PDFY) programme involving six sessions with separate parent and child training, as well as a final session with the family (Spoth 1999a). The remainder of these SFP‐based studies compared the programme versus no programme (Riesch 2012;Skarstrand 2014), or versus an attention control involving the distribution of information leaflets via mail (Brody 2006;Foxcroft 2017).
Seven other universal studies also involved face‐to‐face sessions with small groups of individual parents or families (Estrada 2017; Fosco 2013; Furr‐Holden 2004; Haggerty 2007; Linakis 2013; Loveland‐Cherry 1999; Stevens 2002). Three studies involved group seminars or workshops for parents, with one providing nine sessions (Furr‐Holden 2004), one eight sessions (Estrada 2017), and one seven sessions (Haggerty 2007). Another study involved individual motivational interviewing‐based sessions with parents who were attending an emergency department with a child for a non‐alcohol‐ or drug‐related issue (Linakis 2013). This programme also included telephone booster sessions and mailings and was compared with an enhanced usual care approach including mailing of brochures about the influence of parents on adolescents. One universal study used home visits with families to deliver a motivational interviewing/social cognitive theory‐based intervention and to overcome barriers to assessment of parent elements of interventions and/or parent attendance at school events, with three home sessions plus boosters delivered to families from three school districts and compared with a no program control group randomised at the family level (Loveland‐Cherry 1999). The final universal study involving face‐to‐face sessions delivered at home did so only for families who were identified through the school‐based part of the programme as being at risk (Fosco 2013). As such, this component of the intervention was regarded as the selective component. The universal component of the intervention involved a family resource centre in schools and delivery of special interest face‐to‐face seminars for parents. This intervention was compared with a no programme control
Two universal studies used the Orebro Prevention Program or adaptation (Bodin 2011;Koning 2009). This programme involves presentations to parents at schools and the development of a set of agreed rules among parents. Both studies compared the programme versus a no intervention control, and Koning et al included three arms, also comparing the effectiveness of a student intervention (SI)) with and without the parent intervention (PI; SI+/‐PI versus PI) (Koning 2009).
The remaining 11 universal studies used either paper or computer‐based modules with no face‐to‐face component. Eight studies involved mailing material to parents (e.g. booklets, postcards, audio‐CDs; Bauman 2002; Mares 2016; O'Donnell 2010; Perry 2003; Reddy 2002; Schinke 2004; Werch 2008; Wurdak 2017). Four of these studies compared parent mailings versus a no program or waitlist control (Bauman 2002; Mares 2016; O'Donnell 2010; Wurdak 2017), and four were comparative effectiveness trials (Perry 2003; Reddy 2002; Schinke 2004; Werch 2008), in which parent mailings were assessed as a complement to, or in comparison to, an alternate intervention such as a classroom curriculum (Perry 2003; Reddy 2002), a CD‐ROM programme for adolescents (Schinke 2004), or a set of alternate adolescent postcards (Werch 2008). Four studies were based on mother‐daughter education and a cognitive‐behavioural skills training approach using computer‐ or CD‐ROM‐mediated sessions, all compared with a no program control (Schinke 2009a; Schinke 2009b; Schinke 2009c; Schinke 2011).
Selective interventions
Of the selective interventions, only one study targeted alcohol specifically (Stormshak 2011), with three targeting alcohol and substance use (Fang 2010; Mason 2012; Spirito 2015), and eight targeting alcohol/substance use (Baldus 2016; Catalano 1999; Cordova 2012; Dembo 2001; Milburn 2012; Prado 2012; Wolchik 2002; Wu 2003), along with other problem behaviours such as unsafe sex in Prado 2012 or selling drugs in Wu 2003.
Less variation existed in the interventions delivered in selective studies compared to universal interventions. Ten studies used face‐to‐face sessions with a mixture of group, parent only, or family counselling based on the principles of motivational interviewing, cognitive‐behavioural therapy, or similar counselling approaches (Baldus 2016; Catalano 1999; Cordova 2012; Dembo 2001; Mason 2012; Milburn 2012; Prado 2012; Spirito 2015; Stormshak 2011; Wolchik 2002). The 'intensity' of these interventions ranged from a single family session with assessment task and boosters delivered by mail, as in Spirito 2015, to multiple home visits with families. Two studies used the Family Check‐Up intervention, comprising assessment, feedback, and motivational interviewing principles (Spirito 2015; Stormshak 2011). One study involved five sessions with youth and parents at home (Milburn 2012), two studies involved ten such visits (Dembo 2001; Mason 2012), and one study involved nine group sessions as well as ten family sessions (Family Unidas; Cordova 2012). One study involved 11 group sessions with mothers as well as two individual sessions tailored to the intervention (Wolchik 2002). One study involved a total of 54 contact hours per family, with a mixture of group and individual sessions and a parent retreat (Catalano 1999). Only two selective studies did not involve face‐to‐face contact with parents, with one using a nine‐session web‐based programme targeting mothers' relationships with their daughters (Fang 2010), and the other complementing a face‐to‐face youth programme with a 20‐minute video for parents (Wu 2003).
Most of these selective studies compared an intervention versus either standard practice (e.g. standard methadone clinic, standard referral processes; Catalano 1999; Milburn 2012; Prado 2012), an enhanced 'usual care' condition (Baldus 2016; Cordova 2012; Dembo 2001; Wolchik 2002), or no programme (Fang 2010; Mason 2012; Stormshak 2011). Two selective studies were comparative effectiveness trials that compared the intervention versus an alternative, such as a psychoeducational session in Spirito 2015 or a child‐focused intervention in Wu 2003.
Indicated interventions
Of the indicated interventions, one specifically targeted alcohol (Spirito 2011); three targeted risk behaviours and drug use (including alcohol) (Arnaud 2016; Liddle 2008; Valdez 2013); one targeted substance use including alcohol (Winters 2012); and two targeted alcohol and marijuana use (Spirito 2017; Stanger 2017). In all cases, we considered for this review only outcomes related specifically to alcohol.
All indicated interventions included face‐to‐face sessions based on motivational interviewing (Arnaud 2016; Liddle 2008; Spirito 2011; Spirito 2017), cognitive‐behavioural therapy (Stanger 2017), or brief intervention principles (Valdez 2013; Winters 2012). Intensity varied, with two studies involving a single family motivational interviewing session, as well as a youth component (Spirito 2011; Spirito 2017); one involving two sessions with youth and one with a parent (Winters 2012); and one involving 16 family therapy sessions (Valdez 2013). These interventions were compared with usual care (e.g. referrals, social and behavioural services; in Arnaud 2016 and Valdez 2013) or a no programme control (Winters 2012), and four studies compared the effectiveness of family or parent therapy with adolescent motivational interviewing (Spirito 2011), cognitive‐behavioural therapy (Liddle 2008), or psychoeducation (Spirito 2017). One indicated study compared abstinence‐based incentives in the intervention group versus attendance‐based incentives in the control group (Stanger 2017).
Outcomes
We grouped outcome measures used in meta‐analysis as prevalence, frequency, or volume. Twenty studies reported measures of prevalence (Baldus 2016; Bauman 2002; Bodin 2011; Brody 2006; Catalano 1999; Cordova 2012; Foxcroft 2017; Furr‐Holden 2004; Haggerty 2007; Koning 2009; Mares 2016; O'Donnell 2010; Prado 2012; Reddy 2002; Riesch 2012; Skarstrand 2014; Spoth 1999a; Spoth 2002; Stevens 2002; Wu 2003). These studies included those assessing 'initiation' of or any alcohol in the child's lifetime (Baldus 2016; Bauman 2002; Brody 2006; Foxcroft 2017; Furr‐Holden 2004; Haggerty 2007; Mares 2016; Reddy 2002; Riesch 2012; Skarstrand 2014; Spoth 1999a; Spoth 2002; Stevens 2002), some of which also reported this measure for a cohort of baseline non‐drinkers (Baldus 2016; Bauman 2002; Brody 2006); those reporting the lifetime prevalence of drunkenness (Skarstrand 2014); and those reporting the prevalence of weekly use (Bodin 2011), or use in the last 90 days (Cordova 2012; Prado 2012), 6 months (Catalano 1999; Wu 2003), or 12 months (O'Donnell 2010).
Seventeen studies reported alcohol use frequency outcomes (Arnaud 2016; Dembo 2001; Estrada 2017; Fang 2010; Liddle 2008; Linakis 2013; Milburn 2012; Perry 2003; Schinke 2004; Schinke 2009b; Spirito 2011; Stanger 2017; Valdez 2013; Werch 2008; Winters 2012; Wolchik 2002; Wurdak 2017). These studies all reported on the number of occasions of drinking, with the exception of one study that reported on occasions of binge drinking (Arnaud 2016). Most studies reported frequency of use in the past 30 days (Dembo 2001; Fang 2010; Liddle 2008; Linakis 2013; Schinke 2004; Schinke 2009b; Spirito 2011; Valdez 2013; Werch 2008; Wolchik 2002; Wurdak 2017), and others reported use over time periods of 90 days (Estrada 2017; Milburn 2012; Winters 2012), 36 weeks (Stanger 2017), or 12 months (Perry 2003).
Ten studies reported alcohol use volume outcomes (Arnaud 2016; Fosco 2013; Loveland‐Cherry 1999; Mason 2012; Schinke 2009a; Schinke 2009c; Schinke 2011; Spirito 2015; Spirito 2017; Stormshak 2011). Most reported on the number of drinks consumed in the past 30 days (Arnaud 2016; Fosco 2013; Mason 2012; Schinke 2009a; Schinke 2009c; Schinke 2011; Spirito 2017; Stormshak 2011), and two studies used a quantity‐frequency scale calculated over 3 months in Spirito 2015 and over 12 months in Loveland‐Cherry 1999.
Excluded studies
A total of 179 records remained after title and abstract screening, of which 176 full‐text articles were located for further review. We considered 85 articles to be ineligible after assessment of the full text (reasons for exclusion were study design (N = 15), participants (N = 4), interventions (N = 34), and outcomes (N = 32)). See Characteristics of excluded studies for further details.
Studies awaiting classification
We could not determine the eligibility of three trials, as no full text was available. See Characteristics of studies awaiting classification.
Ongoing studies
We identified 16 ongoing trials by their published protocol or by a clinical trial registration, for which neither published nor unpublished data were available (Characteristics of ongoing studies). These include five trials regarded as universal, two as selective, and nine as indicated.
The universal trials included a C‐RCT comparing a range of health interventions for adolescents, including one related to alcohol and delivered to parents (Ford 2015); an RCT of the Strengthening African American Families STEPS program targeting 11‐15 year‐olds (Kogan 2018), an RCT comparing the Family Matters and Strengthening Families programmes (vs a no program control group) among families with an 11‐ or 12‐year‐old child attending Kaiser Permanente medical centres (Miller 2009); an RCT of a web‐based 'Smart Choices 4 teens' program targeting alcohol and sexual behaviour (Miller 2018), and a C‐RCT of a UK adaptation of the Strenthening Families Program, comparing a seven‐session model versus usual care (Segrott 2014).
The selective trials included an RCT testing the effects of a parenting programme for Latino families versus a waitlist control (Allen 2012), along with an RCT testing an American Indian adaptation of the Strengthening Families programme with orientation towards cultural traditions of Anishinaabe communities versus a no intervention control group (Whitbeck 2016).
The indicated intervention trials included an RCT trialling home‐based behavioural therapy for adolescents with disruptive behaviour disorder and regular substance use versus usual care (Bukstein 2006); a C‐RCT testing an extensive prevention programme involving adolescent and parent components and an indicated component for youth with symptoms of mental health or substance use problems versus treatment as usual (Conrod 2017); an RCT testing the feasibility of a motivational enhancement therapy intervention for adolescents with and without a parenting wisely programme for parents and a drug education programme for adolescents with and without a parenting wisely programme for parents among adolescents with drug‐related charges (Hops 2012); an RCT of enhanced contingency management for adolescents with a current substance use disorder, with and without a parent management training programme (McCart 2017); an RCT of adolescent brief intervention and an e‐parenting skills intervention for parents of adolescents admitted to a trauma service with a positive screening for alcohol or drug use compared to brief intervention alone (Mello 2016); an RCT of multi‐dimensional family therapy compared to family motivational interviewing and a standard care control group for adolescents presenting to the emergency room or trauma unit with alcohol problems (Rowe 2010); an RCT of a contingency management programme compared to usual care for youth in the justice system with a newly opened probation case (Sheidow 2017); an RCT of a computer‐assisted motivational interviewing programme and an online parenting wisely programme for adolescents in the justice system who have a positive result for marijuana use on intake (Spirito 2017b); and an RCT comparing adolescent group therapy versus transitional family therapy for adolescents with a DSM‐IV diagnosis of alcohol abuse or dependence (Stanton 2007).
Risk of bias in included studies
The assessment results of risk of bias for the included studies are presented in Figure 2 and Figure 3. None of the 46 included studies were at low risk in all risk‐of‐bias domains (Higgins 2011). Overall eight studies were regarded as high risk (with three or more 'high' ratings) for the purpose of sensitivity analysis.
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Allocation
Random sequence generation
We rated 11 of the 46 studies at low risk of bias for random sequence generation. Four studies used a computer‐generated random number sequence (Mares 2016; Stevens 2002; Valdez 2013; Wolchik 2002), four studies used urn randomisation (Cordova 2012; Spirito 2015; Spirito 2017; Winters 2012), one study used minimum likelihood allocation (Stanger 2017), and two studies used a coin toss (Bodin 2011; Milburn 2012). We judged the method of sequence generation in one study to be high risk, as four of 20 communities were not randomised and their data were retained (Foxcroft 2017). For the remaining 34 studies, the method of sequence generation was unclear.
Allocation concealment
Of the 46 studies, only seven provided sufficient detail to establish that participant allocation to experimental groups was concealed from those conducting the research; we rated these as having low risk of selection bias for this domain (Bodin 2011; Foxcroft 2017; Koning 2009; Milburn 2012; Prado 2012; Spirito 2011; Spirito 2017). We were unable to make a judgement on the remaining 39 studies using the details provided; therefore, those studies had unclear risk of selection bias with regard to allocation concealment.
Blinding
In all 46 studies, blinding of participants and programme deliverers (performance bias) and blinding of outcome assessment (detection bias) was not achievable due to the nature of the interventions tested and because the outcomes were self‐reported; therefore, we rated these studies as having high risk of performance and detection bias.
Incomplete outcome data
We rated 20 studies at low risk of bias for incomplete outcome data, as they reported less than 20% loss of participants and showed no differential attrition between experimental groups (Arnaud 2016; Baldus 2016; Catalano 1999; Cordova 2012; Dembo 2001; Estrada 2017; Fang 2010; Furr‐Holden 2004; Haggerty 2007; Linakis 2013; Mason 2012; O'Donnell 2010; Perry 2003; Prado 2012; Reddy 2002; Schinke 2009a; Schinke 2009b; Werch 2008; Winters 2012; Wolchik 2002). Sixteen studies had high risk of bias due to high attrition rates (> 20%) or had less than 20% loss of participants but unequal attrition between experiment groups (Bodin 2011; Foxcroft 2017; Koning 2009; Liddle 2008; Loveland‐Cherry 1999; Mares 2016; Milburn 2012; Riesch 2012; Skarstrand 2014; Spirito 2011; Spoth 1999a; Stanger 2017; Stevens 2002; Valdez 2013; Wu 2003; Wurdak 2017). We rated the remaining 10 studies as having unclear risk for incomplete outcome data, as details were insufficient to permit a judgement.
Selective reporting
Five studies had low risk of reporting bias, as outcomes reported were consistent with the prespecified clinical trial registries and/or the study protocol (Bodin 2011; Furr‐Holden 2004; Mares 2016; Spirito 2011; Wurdak 2017). We judged two studies to be at high risk of reporting bias ‐ the first as a direct comparison of the intervention group versus the control group was not presented (Dembo 2001), and the second because an outcome referred to in the protocol was not reported (Foxcroft 2017). We rated the remaining 39 studies as having unclear risk for incomplete outcome data, as details were insufficient to permit a judgement.
Other potential sources of bias
We assessed the potential for contamination bias as another potential source of bias in the 46 studies and judged only one study to be at high risk of contamination (Skarstrand 2014), as study authors noted that control schools were exposed to other alcohol interventions during the intervention period.
For the 16 C‐RCTs, we assessed risk of recruitment bias, baseline imbalances, loss of clusters, incorrect analysis, and compatibility with individually randomised trials (herd effect). We considered seven studies to have low risk of recruitment bias based on appropriate recruitment techniques applied before allocation to clusters, seven to have high risk of bias (based on individual allocation to clusters occurring after randomisation), and the remaining studies to have unclear risk of bias (based on insufficient information). For baseline imbalances, we considered all studies to be at low risk of bias based on similar characteristics of groups at baseline (no baseline imbalances or imbalances accounted for in the analyses), except two studies that provided insufficient information to permit judgement (Arnaud 2016; Spoth 1999a). Only one study had high risk of bias for loss of clusters (Koning 2009). We judged all 16 studies as having low risk for incorrect analysis (based on adequate adjustment for the effect of clustering); however, review authors were required to adjust for clustering on behalf of the authors of four studies (i.e. we did not rate these studies as high risk because we were able to address the lack of adjustment for clustering; Brody 2006; Schinke 2004; Spoth 1999a; Wu 2003). Information was insufficient to permit judgement of the herd effect for all studies.
Effects of interventions
See: Summary of findings for the main comparison Family/parent interventions compared with control for reducing alcohol consumption in adolescents; Summary of findings 2 Family/parent and adolescent interventions compared to adolescent only interventions for reducing alcohol consumption in adolescents
Examination of interventions tested, trial settings, and study populations suggested that the included studies were sufficiently homogenous, and we conducted meta‐analyses by pooling data from trials where interventions and outcome measures were considered similar. Otherwise, we provided a narrative synthesis of trial findings.
For the purposes of meta‐analysis, we pooled outcome measures as those measuring prevalence of alcohol use (including prevalence of lifetime use, any use in the last six months, and weekly use); frequency of use (including the number of occasions of use in the last 30 or last 90 days); and volume of use (including the number of drinks in the previous 30 days or a composite score generated from quantity and frequency measures).
Primary outcomes
Family‐based intervention versus no intervention/standard care
Prevalence of alcohol use
Any family‐based intervention versus no intervention/standard care
Overall, meta‐analytical pooling of post‐intervention data revealed that there was no intervention effect on the prevalence of alcohol use (standardised mean difference (SMD) 0.00, 95% confidence interval (CI) ‐0.08 to 0.08; studies = 12; participants = 7490; I² = 57%; Analysis 1.1; low‐quality evidence). Results were similar in sensitivity analyses of studies with low risk of bias (SMD ‐0.12, 95% CI ‐0.35 to 0.11; studies = 4; participants = 1733; I² =73%; Analysis 1.4).
In subgroup analyses by prevention approach, results were similar.
Universal family‐based intervention versus no intervention/standard care
Results show SMD 0.02 (95% CI ‐0.06 to 0.11; studies = 10; participants = 189; I² = 60%; Analysis 1.5).
Selective or indicated family‐based intervention versus no intervention/standard care
Results show SMD ‐0.16 (95% CI ‐0.36 to 0.05; studies = 2; participants = 357; I² = 0%; Analysis 1.6).
Effects on alcohol use prevalence were also consistent in subgroup analysis including the three studies whose participant population was regarded as a minority ethnic group (Brody 2006; Haggerty 2007; Riesch 2012) (SMD ‐0.20, 95% CI ‐0.42 to 0.02; studies = 3; participants = 325; I² = 0%; Analysis 1.9).
Results remained consistent with the main analysis for studies regarded as providing low‐intensity interventions (Analysis 1.7), those reporting on outcomes measured more than 12 months from randomisation or intervention delivery (Analysis 1.8), those primarily including an ethnic majority or Caucasian participants (Analysis 1.10), and those measuring lifetime or past six month use of any alcohol as opposed to heavy consumption (Analysis 1.11).
Several studies that could not be pooled measured alcohol use prevalence and reported mixed results in keeping with the meta‐analysis. Furr‐Holden 2004 collected data at five, six, and seven years post randomisation and reported that they found little evidence of the effect of their universal intervention on early onset of alcohol use. O'Donnell 2010 evaluated a universal parent education programme targeting parents of girls and reported that fewer girls in the intervention group drank at follow‐up than in the control group (Adjusted Odds Ratio [AOR] 0.38, 95% CI 0.15 to 0.97; P < 0.05) but did not report participant numbers by group to enable pooling. Two studies could not be pooled because the only data available conveyed the results of linear growth curve analyses. Cordova 2012 reported significant effects of their selective intervention on past 90 day alcohol use among US‐born adolescents (regression coefficient/slope [b] = ‐0.425, P = 0.017) but not among foreign‐born adolescents (b = 0.172, P = 0.357). Also, overall, the increase in alcohol use from baseline to 30‐month follow‐up was more modest than that observed in the control group. Prado 2012 report that although their selective Familias Unidas intervention was efficacious in reducing substance use, investigators found no intervention effect specific to current alcohol use (b = ‐0.47, P = 0.14).
Frequency of alcohol use
Any family‐based intervention versus no intervention/standard care
Overall, meta‐analytical pooling of these studies revealed no intervention effects with substantial variability and heterogeneity (SMD ‐0.31, 95% CI ‐0.83 to 0.21; studies = 8; participants = 1835; I² = 96%; Analysis 1.2; very low‐quality evidence). Sensitivity analysis including only studies with low risk of bias showed overall no intervention effects and heterogeneity that remained substantial (SMD 0.09, 95% CI ‐0.24 to 0.43; studies = 5; participants = 1488; I² = 87%; Analysis 1.12).
Subgroup analysis
Universal family‐based intervention versus no intervention/standard care
Universal studies measuring the effectiveness of parent/family interventions found no effects overall on frequency of alcohol use (SMD 0.18, 95% CI ‐0.40 to 0.75; studies = 3; participants = 1090; I² = 92%; Analysis 1.13).
Selective or indicated family‐based intervention versus no intervention/standard care
We pooled selective and indicated trials together as only one selective study reported alcohol use frequency. In this meta‐analysis, the interventions again had no effect, although the SMD indicated slight favouring of the intervention (SMD ‐0.65, 95% CI ‐1.64 to 0.33; studies = 5; participants = 745; I² = 97%; Analysis 1.14).
We observed a similar lack of effect in subgroup analyses including only studies with follow‐up of outcome measures more than 12 months from intervention delivery or randomisation (SMD ‐0.31, 95% CI ‐0.83 to 0.21; studies = 8; participants = 1835; I² = 96%; Analysis 1.15) and those including ethnic majority or Caucasian participants (SMD 0.15, 95% CI ‐0.13 to 0.43; studies = 5; participants = 799; I² = 71%; Analysis 1.17). The effects of interventions delivered to ethnic minority groups approached significance (SMD ‐1.19, 95% CI ‐2.83 to 0.46; studies = 3; participants = 1037; I² = 98%; Analysis 1.16).
Studies that could not be pooled reported mixed effects on alcohol use frequency but overall were consistent with the lack of effects revealed in meta‐analysis. Two studies reported data from growth curve analyses only (Dembo 2001; Estrada 2017). Dembo 2001 reported that youth who completed their selective Family Empowerment intervention reported getting drunk on alcohol less often than those who did not complete the programme. Data specific to intervention effects by group are not presented, with analysis focusing on predictors of drunkenness frequency. Estrada 2017 used growth curve analyses to examine trajectories of alcohol and drug use and reported no significant effects of their universal intervention on 90‐day alcohol use. Wolchik 2002 reported outcomes beyond four years post randomisation, but we excluded these from meta‐analysis due to heterogeneity. These study authors reported that they observed no significant alcohol effects of their selective mother plus child programme for children of divorce compared with control, but they noted significant effects of the mother only programme on alcohol consumption compared to control (P = 0.005).
One study provided no data regarding error of measurement, meaning that the data were not usable (Milburn 2012). Milburn 2012 report a significant effect of their selective cognitive‐behavioural therapy intervention on the number of occasions of alcohol use in the three months before assessment (effect size = 0.38, P = 0.003) but did not report whether alcohol was used by homeless youth in the trial. This study also reported that intervention participants reduced alcohol use significantly more than those given the control (P= 0.003).
Volume of alcohol use
Any family‐based intervention versus no intervention/standard care
Overall, meta‐analysis revealed a very small effect of parent/family interventions on alcohol consumption volume (SMD ‐0.14, 95% CI ‐0.27 to 0.00; studies = 5; participants = 1825; I² = 42%; Analysis 1.3; low‐quality evidence). We performed sensitivity analysis that included studies rated as having low risk of bias and found that results remained consistent but showed increased variability and heterogeneity (SMD ‐0.15, 95% CI ‐0.32 to 0.03; studies = 4; participants = 1397; I² = 52%; Analysis 1.19).
Subgroup analyses by prevention approach yielded similar results.
Universal family‐based intervention versus no intervention/standard care
We performed a subgroup analysis pooling universal studies measuring alcohol consumption volume, including three studies and maintaining a small positive effect of interventions (SMD ‐0.21, 95% CI ‐0.32 to ‐0.10; studies = 3; participants = 1481; I² = 0%; Analysis 1.20).
Selective or indicated family‐based intervention versus no intervention/standard care
One selective study ‐ Mason 2012 and one indicated study ‐ Arnaud 2016 ‐ were pooled together, revealing no overall effects of these interventions on alcohol volume (SMD 0.06, 95% CI ‐0.15 to 0.27; studies = 2; participants = 344; I² = 0%; Analysis 1.21).
We performed further subgroup analyses and found intervention effects remaining small for studies involving ethnic minority groups (SMD ‐0.24, 95% CI ‐0.36 to ‐0.12; studies = 3; participants = 1081; I² = 0%; Analysis 1.23) and for studies including females only (SMD ‐0.25, 95% CI ‐0.37 to ‐0.13; studies = 2; participants = 1053; I² = 0%; Analysis 1.25). Effects were absent for studies measuring outcomes at or beyond 12 months from intervention delivery or randomisation (SMD ‐0.16, 95% CI ‐0.35 to 0.02; studies = 3; participants = 988; I² = 30%; Analysis 1.22) and for studies including ethnic majority or Caucasian participants (SMD ‐0.01, 95% CI ‐0.17 to 0.15; studies = 2; participants = 744; I² = 0%; Analysis 1.24).
Three studies that could not be pooled reported intervention effects on alcohol use volume. Fosco 2013 reported data from latent growth curve analyses showing that their universal intervention was associated with an increase in students' self‐regulation, which in turn was associated with a reduction in risk for antisocial behaviours including alcohol use that was significant at the P < 0.05 level. Stormshak 2011 conducted complier average causal effect (CACE) modelling to examine treatment effects on youth whose families engaged with the selective Family Check‐Up intervention and reported that the intervention was successful in reducing the growth of alcohol use and other risk behaviours among middle school youth. Schinke 2009a did not report sample numbers by group for their universal programme, precluding pooling. Intervention by time interactions found that intervention arm girls reported less alcohol consumption than control arm girls over the past week (P < 0.01), month (P < 0.05), and year (P < 0.01).
Family‐based and adolescent intervention versus intervention with young people alone
Prevalence of alcohol use
Any family‐based and adolescent interventions versus interventions with young people alone
Overall, researchers found no effect of parent/family interventions on alcohol use prevalence compared to interventions with young people alone (SMD ‐0.39, 95% CI ‐0.91 to 0.14; studies = 4; participants = 5640; I² = 99%; Analysis 2.1; very low‐quality evidence). The interventions trialled in these studies included both family/parent and youth components and were compared with youth components only.
Sensitivity analysis limited to those studies with low risk of bias yielded similar results (SMD ‐0.61, 95% CI ‐1.84 to 0.63; studies = 2; participants = 3891; I² = 100%; Analysis 2.3).
Subgroup analyses
Universal family‐based and adolescent interventions versus interventions with young people alone
Also, we detected no effects in subgroup analysis including universal studies only (SMD ‐0.44, 95% CI ‐1.08 to 0.20; studies = 3; participants = 5351; I² = 99%; Analysis 2.4).
Insufficient numbers of studies precluded other subgroup analyses.
We did not pool two studies due to lack of experimental isolation of the parent component of the intervention (Spirito 2015), or to heterogeneity of the comparison group (Stevens 2002). Spirito 2015 compared a selective parent‐focused intervention versus a brief psychoeducational intervention for adolescents in which parents attended the sessions; both conditions involved booster mail‐outs for parents over a six‐month period. This study reported a significant interaction of the study condition by time on adolescent report of refusal to drink alcohol (F(1,56) = 7.05, P < 0.05, partial ɳ² = 0.11), such that adolescents in the family check‐up intervention condition reported significant increases in alcohol refusal from baseline to six months when compared to adolescents in the psychoeducational condition, who reported significant decreases in alcohol refusal. Stevens 2002 compared a universal family‐based alcohol and tobacco programme delivered through paediatric primary care versus a family‐based safety (gun, seatbelt, bicycle helmet) programme, also delivered through paediatric primary care. Researchers reported no significant intervention effects.
Frequency of alcohol use
Comparative effectiveness trials measuring alcohol use frequency reported no effects overall. The SMD slightly favoured a decreased frequency of use, but variability and heterogeneity were substantial (SMD ‐0.16, 95% CI ‐0.42 to 0.09; studies = 4; participants = 915; I² = 73%; Analysis 2.2; very low‐quality evidence). Sensitivity analysis with the three studies classified as low risk of bias remained consistent (SMD ‐0.21, 95% CI ‐0.50 to 0.08; studies = 3; participants = 432; I² = 80%; Analysis 2.3).
Subgroup analyses
Two universal studies measuring alcohol use frequency were pooled in a subgroup analysis, again revealing an absence of intervention effect (SMD ‐0.30, 95% CI ‐0.68 to 0.07; studies = 2; participants = 596; I² = 84%; Analysis 2.6) versus interventions with young people alone (Schinke 2004; Werch 2008). Similarly, twoindicated studies measuring alcohol use frequency showed no overall effect (SMD 0.01, 95% CI ‐0.21 to 0.23; studies = 2; participants = 319; I² = 0%; Analysis 2.7) (Spirito 2011; Winters 2012). These studies compared interventions targeted towards adolescents only, such as a CD‐ROM programme (Schinke 2004), postcards containing health promotion messages (Werch 2008), individual motivational interviewing (Spirito 2011), and adolescent brief intervention (Winters 2012), with interventions which included these adolescent components along with parent involvement.
Results among two of the three studies that could not be pooled in this category remained consistent with the overall lack of intervention effects. Perry 2003 conducted linear growth curve analyses and reported that the universal DARE plus program enhanced the DARE curriculum, with both girls and boys in the DARE Plus group less likely to increase their alcohol use over time. We did not pool two studies due to heterogeneity and the lack of experimental isolation of the parent component of the intervention. Spirito 2017 compared an indicated parent‐focused intervention versus a brief psychoeducational intervention for adolescents in which parents attended the sessions, and both conditions involved booster mail‐outs for parents over a six‐month period. This study reported no treatment effect by condition. Similarly, in their indicated intervention programme, Liddle 2008 compared multi‐dimensional family therapy versus cognitive‐behavioural therapy delivered to adolescents but with parents involved in the first two sessions and in signing a treatment contract. No differential treatment effects were reported for alcohol use between groups.
Volume of alcohol use
No comparative effectiveness trial reporting on the volume of alcohol use could be pooled in meta‐analysis.
Secondary outcomes
Several studies reported secondary outcomes in addition to alcohol use outcomes, but we did not pool these due to the heterogeneity of measures.
Universal interventions
One study reported on parental supply of alcohol at home following a universal intervention based on the Orebro programme and noted a statistically significant programme effect compared to control at 12 months' and 30 months' follow‐up using intention‐to‐treat analysis (P = 0.03 and 0.01, respectively) and using multiple imputation at 30 months only (P = 0.02) (Bodin 2011).
Another study measured alcohol misuse following a universal intervention involving three family sessions at home (Loveland‐Cherry 1999). Researchers used a composite of eight items and found that prior drinkers in the intervention condition reported less alcohol misuse and a sharper decline in alcohol problems than prior drinkers in the control group, but those who were not prior drinkers showed a slight increase in alcohol misuse, with intervention group participants only reporting minimally lower rates of misuse than control group participants. Effects of the intervention condition by time interaction were significant for alcohol misuse (P < 0.01). We did not include this outcome in the meta‐analysis as the study also reported a quantity‐frequency composite, which we used in the alcohol use volume category.
Schinke 2004 measured family involvement including monitoring and the number of times parents had spoken to adolescents about not drinking following a universal CD‐ROM‐based programme. Study authors reported higher family involvement scores at two and three years' follow‐up among the intervention group versus the control group.
Selective interventions
Prado 2012 reported on a diagnosis of alcohol dependence using adolescent reports on the Diagnostic Interview Schedule for Children (DISC) predictive scales following a selective intervention based on family and group counselling sessions. This study reported a decrease in the percentage of adolescents with dependence in the intervention group and an increase in the control group. In growth curve analysis, the difference over time between groups was significant (b = ‐1.16, P = 0.02, P = 0.93).
Indicated interventions
Two studies of indicated interventions reported relevant secondary outcomes. Winters 2012 used an Adolescent Diagnostic Interview (ADI) following a brief intervention‐based programme to measure symptoms of both alcohol abuse and dependency in the prior 90 days, and reported effect sizes of 2.0 and 2.1, respectively, with higher rates of 'absence' of these symptoms in the intervention group than in the control group (P < 0.01 for both).
Arnaud 2016 also measured alcohol problems using the brief Rutgers Alcohol Problems Index following their brief motivational interviewing programme. Study authors report that although alcohol problems were reduced over time in both intervention and control groups, between‐group differences were not significant.
Discusión
Resumen de los resultados principales
Esta actualización y expansión de una revisión anterior ‐ Foxcroft 2011a ‐ identificó un gran número de ensayos controlados aleatorios (ECA) y ensayos controlados con asignación al azar grupal (ECA‐G) que investigan las intervenciones familiares orientadas a la reducción del consumo de alcohol en los jóvenes. Se ha incluido un total de 46 estudios en esta revisión.
En general esta revisión sistemática integral y metanálisis encontraron poca evidencia para indicar que las intervenciones universales, selectivas e indicadas con padres o familias son efectivas para reducir las medidas de consumo de alcohol en adolescentes (prevalencia, frecuencia y volumen de alcohol consumido) en comparación con ninguna intervención o la atención estándar. Alguna evidencia indica que en determinadas circunstancias, las intervenciones familiares universales y selectivas/indicadas tuvieron efectos pequeños y diferenciales sobre las medidas del consumo de alcohol en los adolescentes; sin embargo, considerando la cantidad de análisis realizados, la variación en los efectos observados, el alto riesgo de sesgo evaluado entre los estudios y el nivel de la heterogeneidad observada, la interpretación general de los resultados indica la ausencia de efecto.
El análisis de los estudios que comparan los efectos de una intervención familiar versus ninguna intervención o el control de atención habitual sobre la prevalencia del consumo de alcohol no demostró ninguna repercusión. Los análisis de subgrupos que examinaron los efectos de las intervenciones selectivas e indicadas, orientadas a los grupos de adolescentes en riesgo o que ya consumen alcohol, no demostraron ningún efecto claro sobre la prevalencia del consumo de alcohol. De manera similar, los resultados no muestran ninguna repercusión discernible de los estudios que comparan una intervención familiar como parte de otra intervención versus la otra intervención sola. Los estudios que no pudieron agruparse informaron sobre resultados contradictorios; tres estudios no informaron de ningún efecto de la intervención (Furr‐Holden 2004; Prado 2012; Spirito 2015), y tres informaron sobre algunos efectos positivos estadísticamente significativos (Cordova 2012; O'Donnell 2010; Stevens 2002).
En general no se halló evidencia clara de los efectos de la intervención sobre la frecuencia del consumo de alcohol, aunque los modelos observados en los análisis de subgrupos merecen consideración adicional. El metanálisis de todos los estudios que midieron los efectos de las intervenciones familiares/de padres en comparación con el control en la frecuencia del consumo de alcohol tampoco logró mostrar una reducción de este resultado. Los análisis de subgrupos indican que las intervenciones universales orientadas a los grupos de bajo riesgo tienen el potencial de efectos perjudiciales sobre este resultado, y las intervenciones selectivas e indicadas tienen una mayor probabilidad de favorecer una reducción en la frecuencia del consumo. El potencial de efectividad también se observa en los análisis de subgrupos de los estudios que se centran en grupos de minorías étnicas. Se encontró un efecto positivo pequeño en el metanálisis de los ensayos de efectividad comparativa. De los siete estudios que no pudieron agruparse, cuatro informaron de algunos efectos positivos de las intervenciones sobre la frecuencia del consumo de alcohol (Dembo 2001; Milburn 2012; Perry 2003; Wolchik 2002), y tres no informaron ningún efecto diferencial entre los grupos (Estrada 2017; Liddle 2008; Spirito 2017).
Es posible que en los grupos de riesgo bajo tratados en las intervenciones universales, y representados en las poblaciones de mayorías étnicas, no se logren demostrar los efectos positivos debido a una menor prevalencia en la población del consumo de alcohol (lo que dificulta la identificación de diferencias entre los grupos de estudios con un poder estadístico inadecuado). Por el contrario, los grupos de riesgo mayor como los estudiados en las intervenciones selectivas e indicadas tienen tasas mayores de consumo, lo cual da lugar a que la detección de las diferencias sea más realizable. También es posible que la frecuencia del consumo sea una medida más relevante y potente del efecto en los estudios selectivos e indicados, y la reducción en la frecuencia del consumo una expectativa más realista para los participantes que están en riesgo o ya consumen alcohol. Entre las poblaciones estudiadas en las intervenciones universales, se espera que ocurra un aumento natural de la prevalencia del consumo con el transcurso del tiempo tanto en los grupos de intervención como de control. Los modelos observados plantean una pregunta sobre si la posibilidad de destacar el tema del consumo en los programas de intervención podría en realidad estimular más este aumento en los grupos de intervención que en los grupos de control.
También se observaron modelos diferentes en el metanálisis de los estudios que medían los efectos de la intervención sobre el volumen de alcohol consumido. En los análisis de subgrupos, las intervenciones clasificadas como universales tuvieron un efecto pequeño que favorece las intervenciones sobre el volumen de alcohol consumido, al igual que el subgrupo de estudios con participantes de minorías étnicas y los que incorporaron sólo mujeres. Los dos estudios agrupados que probaron intervenciones selectivas o indicadas revelaron un efecto negativo general (potencialmente nocivo) sobre el volumen de alcohol consumido. No fue posible agrupar los ensayos de efectividad comparativa que midieron el volumen de alcohol consumido. Tres estudios que no pudieron agruparse informaron efectos positivos de la intervención sobre el volumen de alcohol consumido (Fosco 2013; Schinke 2009a; Stormshak 2011). Sin embargo, estos modelos deben interpretarse con cuidado ya que hubo números pequeños de estudios que contribuyeron a cada uno de estos resultados y a los análisis de subgrupos de los estudios que incluían sólo a mujeres, incluidos dos estudios realizados por el mismo grupo (Schinke 2009c; Schinke 2011). Se necesita una gama más amplia de estudios independientes para contribuir a estos análisis y confirmar los efectos dudosos observados aquí.
A pesar de estas limitaciones, los modelos observados merecen investigación adicional. Los modelos son de alguna manera contradictorios en cuanto a los informados para la frecuencia del alcohol anteriormente, lo cual sugiere que puede haber diferencias importantes entre estas construcciones. Es posible que de una manera similar al consumo en adultos, el consumo de alcohol en adolescentes varíe como un producto de estas dos medidas, y que el consumo menos frecuente aunque de volumen mayor represente un mayor riesgo que lo opuesto.
Los efectos en los resultados secundarios no pudieron agruparse debido a la heterogeneidad y los resultados fueron contradictorios. Bodin informó efectos positivos de la intervención sobre el suministro parental de alcohol a los 12 y 30 meses después del ensayo del programa de prevención Orebro. Un estudio universal midió los resultados del uso inadecuado de alcohol (Loveland‐Cherry 1999), y encontró efectos positivos de la intervención informados entre los participantes que eran bebedores antes del inicio pero efectos negativos informados entre los que no lo eran.
Un estudio selectivo (Prado 2012) y uno indicado (Winters 2012) midió el consumo excesivo de alcohol y la dependencia; en ambos casos, se informaron tasas inferiores de estos diagnósticos en los grupos de intervención, aunque Winters 2012 informó de diferencias significativas sólo en la intervención breve con adolescentes y padres versus control (y no versus intervención breve con adolescentes sola). Un programa indicado también midió los problemas relacionados con el alcohol y no encontró ninguna diferencia entre los grupos (Arnaud 2016).
En todos los tipos de intervenciones, los programas se centraron de manera sistemática en las relaciones entre padres e hijos y la comunicación y en la promoción de enfoques de parentalidad positiva para reducir el consumo de alcohol u otras sustancias. No hay diferencias claras discernibles entre las intervenciones usadas en los ensayos efectivos e inefectivos. Los resultados muestran un modelo de mayor intensidad del programa en las intervenciones selectivas e indicadas, que vale la pena considerar. Kuntsche 2016 sugirió que la mayor intensidad del programa de las intervenciones de padres se asocia con una mayor efectividad, aunque observó que las intervenciones efectivas de alta intensidad son probadas más comúnmente en las poblaciones de alto riesgo. Es posible que en las intervenciones selectivas e indicadas y con grupos de adolescentes de mayor edad, las intervenciones de alta intensidad sean más apropiadas, pero que las intervenciones universales tengan mayor probabilidad de ser efectivas cuando requieren un compromiso de los padres menos intensivo o cara a cara. Dentro de las intervenciones universales, a un nivel de estudio individual, existe un modelo mediante el cual los estudios efectivos (p.ej. Bodin 2011, Schinke 2009b, Schinke 2009c) requieren menos compromiso de los padres cara a cara que los que son inefectivos (p.ej. Linakis 2013, Spoth 2002). El análisis de subgrupos que incluye sólo los estudios universales considerados como de menor intensidad (definidos como autodirigidos, mediados por computadora, o que incluyen contacto cara a cara que coincide con otros compromisos de los padres en escuela) se aproxima a la importancia aunque aún es sumamente heterogéneo (no observado).
Las intervenciones selectivas e indicadas tendieron a ser orientadas hacia los adolescentes mayores, con edades promedio aproximadas para los estudios universales, selectivos e indicados de 12; 13 y 15,5 años, respectivamente. Dos estudios incluyeron grupos de participantes cuya edad promedio era menor a los 10 años (Furr‐Holden 2004; Loveland‐Cherry 1999). Uno de los mismos ‐ Furr‐Holden 2004 ‐ no se incluyó en el metanálisis por otras razones, aunque cuando se realizó un análisis de subgrupos excluyendo a Loveland‐Cherry 1999 los resultados no difirieron (no informado). Estos modelos de una mayor edad y una mayor intensidad del programa para el aumento del nivel de riesgo de los participantes probablemente reflejan una aplicación apropiada del concepto de universalismo proporcional (Marmot 2010).
Compleción y aplicabilidad general de las pruebas
Cuarenta y seis ensayos con 39 822 participantes asignados al azar cumplieron con los criterios de inclusión para esta revisión. La mayoría de los ensayos (n = 29) se informaron en los Estados Unidos; otros se realizaron principalmente en Europa (Países Bajos, Alemania, Polonia, Suecia); y solo un estudio, Reddy 2002, se realizó en un país en desarrollo (India). Este hecho limita la validez externa de la evidencia y la generalizabilidad de los resultados a las naciones en desarrollo. Seis ensayos fueron sólo en mujeres e informaron de intervenciones específicas de género. Sin embargo, el análisis de subgrupos por género fue limitado, ya que estos estudios no informaron de resultados comparables. También cuatro de estos seis estudios estaban relacionados con el mismo programa y fueron realizados por el mismo investigador primario, lo cual significa que se necesitan estudios adicionales independientes para fortalecer la evidencia asociada con la repercusión de las intervenciones familiares en el consumo de alcohol en las niñas. La edad de los adolescentes considerados en los estudios incluidos en gran parte representa a los niños de la edad escolar secundaria antes o durante el momento en que comúnmente se observa la iniciación al alcohol. Esta revisión excluyó los estudios orientados a los adolescentes que ingresaban a la universidad, debido a que la función de los padres es diferente en este contexto y el asesoramiento tiene que representar a los estudiantes que probablemente van a mudarse del hogar al ámbito de viviendas de la universidad. Por lo tanto los estudios incluidos son más homogéneos en su limitación a los adolescentes de una edad promedio de menos de 18 años. Los contextos de estudio y los programas familiares incluidos fueron compatibles con los encontrados en el ámbito de prevención en los Estados Unidos y Europa.
Calidad de la evidencia
A pesar de las mejorías con el transcurso del tiempo en la calidad metodológica de los ensayos de la prevención del abuso de alcohol para los jóvenes (Foxcroft 2011a), aún hay limitaciones metodológicas importantes y problemas de informe. En general, 17 de los estudios incluidos se consideraron en alto riesgo para el análisis de sensibilidad. Aunque estos análisis no dieron lugar a diferencias discernibles en los resultados del estudio, es importante observar el origen común del sesgo entre los estudios incluidos; la mayoría de los estudios se consideraron en riesgo alto de sesgo para el cegamiento de los participantes y el personal y para el cegamiento de la evaluación de resultado, debido a la naturaleza de las intervenciones y el diseño de estudio. La mayoría de los estudios aportaron detalles insuficientes para permitir la evaluación de la asignación (sesgo de selección) y sesgo de informe.
Se utilizaron los criterios GRADE para evaluar la calidad de la evidencia para el resultado primario del consumo de alcohol, y se realizaron evaluaciones por separado para cada resultado y tipo de comparación. Ver "Resumen de resultados", tabla 1 y 2. La calidad de la evidencia para la reducción en el consumo de alcohol varió de baja a muy baja.
Se evaluó la calidad de la evidencia para los ensayos que compararon las intervenciones familiares/de padres versus ninguna intervención/atención estándar en cuanto a la reducción de la prevalencia del consumo de alcohol como baja debido a la disminución por el riesgo de sesgo y la heterogeneidad no explicada. La disminución por el riesgo de sesgo (un nivel) se debió a las clasificaciones del riesgo poco claro de sesgo en varios dominios y la disminución por la heterogeneidad (un nivel) se debió a la heterogeneidad moderada que se explicó sólo de manera parcial en los análisis de subgrupos. No se disminuyó la calidad por el sesgo de publicación debido a la simetría en los gráficos en embudo (Figura 4; Figura 5; Figura 6).
Se evaluó la calidad de la evidencia para los ensayos que comparaban las intervenciones familiares/de padres versus ninguna intervención/atención estándar en la reducción de la frecuencia del consumo de alcohol como muy baja debido a la disminución por el riesgo de sesgo, la heterogeneidad y la imprecisión. La disminución en un nivel por el riesgo de sesgo se debió a las clasificaciones de riesgo alto o poco claro de sesgo en varios dominios. La disminución en dos niveles por la heterogeneidad estuvo relacionada con la heterogeneidad alta que no se explicó en los análisis de subgrupos. La disminución en un nivel por la imprecisión de los resultados fue el resultado de un intervalo de confianza amplio que cruzó tanto ‐0,5 como cero, lo cual significa que el efecto cierto podría ser beneficioso o perjudicial.
Se evaluó como baja la calidad de la evidencia de los ensayos que comparan las intervenciones familiares/de padres versus ninguna intervención/atención estándar en la reducción del volumen de alcohol consumido a causa de la disminución de un nivel, debido al riesgo alto o poco claro de sesgo de las calificaciones de sesgo en varios dominios, y la disminución de un nivel debido a una alta probabilidad de sesgo de publicación. Se evaluó el riesgo de sesgo de publicación como alto debido a la proporción pequeña de estudios incluidos que pudieron agruparse en el metanálisis.
Para los ensayos de efectividad comparativa, se evaluó la calidad de la evidencia para la medición de la prevalencia del consumo de alcohol como muy baja debido a la disminución por las clasificaciones del riesgo de sesgo alto o poco claro en varios dominios (un nivel) y la imprecisión de los resultados (un nivel) con un intervalo de confianza amplio que cruza tanto ‐0,5 como cero, lo cual significa que el efecto cierto podría ser beneficioso o perjudicial. Además, se disminuyó la calificación de esta evidencia en dos niveles debido a la heterogeneidad alta que no se explicó en los análisis de subgrupos. Se consideró que los ensayos de efectividad comparativa que midieron las frecuencias del consumo de alcohol aportaron evidencia de muy baja calidad debido a la disminución por el riesgo de sesgo (un nivel), la heterogeneidad (un nivel), y la imprecisión (un nivel). La disminución por la imprecisión de los resultados fue el resultado de un intervalo de confianza amplio que cruzó tanto ‐0,5 como cero y un tamaño de la muestra relativamente pequeño, lo cual significa que el efecto cierto podría ser beneficioso o perjudicial.
Sesgos potenciales en el proceso de revisión
Esta revisión utilizó una metodología integral y rigurosa y una estrategia de búsqueda amplia, y pares de autores de revisión independientes realizaron la selección, la extracción de datos y la evaluación del riesgo de sesgo. Además, los autores de la revisión no restringieron las publicaciones en base al idioma. Por lo tanto, es poco probable que se hayan perdido ensayos relevantes. Se buscó más información para cinco de los estudios incluidos mediante el contacto con el autor principal correspondiente; se recibió información de dos de estos autores de los estudios.
Acuerdos y desacuerdos con otros estudios o revisiones
El esfuerzo para actualizar y ampliar la revisión Foxcroft 2011a llevó a la inclusión de 34 estudios adicionales y permitió el agrupamiento metanalítico de los datos. Este análisis ha desplazado el resultado global de un resultado de efectos positivos alentadores a uno de esencialmente ningún efecto. Es importante considerar la heterogeneidad significativa y los sesgos potenciales de los estudios incluidos en cualquier interpretación de los resultados actuales. Estos resultados también presentan algunos conflictos con los informados por Smit 2008 en una revisión realizada antes de la revisión Foxcroft Cochrane, así como en una actualización reciente de Kuntsche 2016. Cada una de estas revisiones apunta hacia efectos pequeños aunque positivos de las intervenciones de prevención familiares universales. El agregado de 12 estudios de intervención selectiva y de siete de intervención indicada a esta revisión demuestra la efectividad probablemente diferencial de los programas de intervención según la población destinataria, y se observan efectos de intervención positivos menos claros a través de estos estudios. El análisis de las medidas de resultado presentadas en esta revisión también podría explicar las diferencias en los resultados, con efectos que difieren en cuanto a las medidas de prevalencia, frecuencia y volumen de consumo.
Kuntsche 2016 realizó una revisión bibliográfica sistemática de las intervenciones de padres para prevenir o reducir la consumo de sustancias en adolescentes, e incluyó 39 publicaciones sobre 13 programas de intervención. Cinco de los programas incluidos también están incluidos en esta revisión, aunque Kuntsche 2016 incluyó sólo estudios publicados en los 12 años desde la publicación de una revisión anterior (Petrie 2007), estudios que incluían a adolescentes de una media de edad de 10 a 18 años (con la exclusión de los estudios en niños más pequeños) y estudios que informaban la iniciación del consumo de alcohol, tabaco, o cannabis como un resultado. Esta revisión también incluyó algunos estudios cuasiexperimentales con un diseño pre‐posevaluación. Los autores de revisión establecieron la conclusión de que el apoyo a los padres para mejorar la comunicación entre padres e hijos y para vigilar las actividades de su descendencia mientras se proporcionan reglas estrictas contra el consumo de sustancias a los menores de edad puede ayudar a frenar el consumo de sustancias en los adolescentes. Los autores de revisión observaron varias limitaciones y brechas en su revisión que requieren investigación adicional. Estas preguntas se relacionan en particular con la intensidad del programa, con una tendencia observada en la cual la intensidad de un programa tiene una repercusión directa sobre su efectividad, y cuando los programas más intensos son investigados con más frecuencia en las poblaciones de mayor edad y de alto riesgo (minoría étnica). Al igual que lo identificado también en la presente revisión, aún quedan dudas en cuanto a la intensidad con relación a los tipos de programas (universal, selectivo, indicado) y a las edades y los tipos de participantes. Además, esta revisión informa en forma narrativa sobre los resultados de los estudios incluidos agrupados de manera general como estudios que investigan el consumo de alcohol, la embriaguez o los problemas con el alcohol.
Vermeulen‐Smit 2015 examinaron una serie similar de estudios, incluidos 39 artículos que informaban sobre 18 programas diferentes pero que describían los resultados relacionados con las sustancias ilícitas. Estos autores de revisión incluyeron sólo programas en los cuales al menos la mitad de la intervención se orientaba a los padres e informaron que dichos programas tuvieron un efecto favorable pequeño sobre la iniciación y la frecuencia del consumo de marihuana aunque no aportaron ninguna evidencia clara de una repercusión sobre el consumo de otras drogas ilícitas.
Study flow diagram.
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Funnel plot of comparison: 1 Parent/family intervention vs control_2, outcome: 1.1 Alcohol use_Prevalence.
Funnel plot of comparison: 1 Parent/family intervention vs control_2, outcome: 1.5 Subgroup_universal_Alcohol use_Prevalence.
Funnel plot of comparison: 1 Parent/family intervention vs control_2, outcome: 1.8 Subgroup_>12 months_Alcohol use_Prevalence.
Comparison 1 Any parent/family intervention vs no intervention/standard care, Outcome 1 Alcohol use_Prevalence.
Comparison 1 Any parent/family intervention vs no intervention/standard care, Outcome 2 Alcohol use_Frequency.
Comparison 1 Any parent/family intervention vs no intervention/standard care, Outcome 3 Alcohol use_Volume.
Comparison 1 Any parent/family intervention vs no intervention/standard care, Outcome 4 Sensitivity_RoB_Alcohol use_Prevalence.
Comparison 1 Any parent/family intervention vs no intervention/standard care, Outcome 5 Subgroup_universal_Alcohol use_Prevalence.
Comparison 1 Any parent/family intervention vs no intervention/standard care, Outcome 6 Subgroup_selective/indicated_Alcohol use_Prevalence.
Comparison 1 Any parent/family intervention vs no intervention/standard care, Outcome 7 Subgroup_low intensity_Alcohol use_Prevalence.
Comparison 1 Any parent/family intervention vs no intervention/standard care, Outcome 8 Subgroup_>12 months_Alcohol use_Prevalence.
Comparison 1 Any parent/family intervention vs no intervention/standard care, Outcome 9 Subgroup_ethnicity minority_Alcohol use_Prevalence.
Comparison 1 Any parent/family intervention vs no intervention/standard care, Outcome 10 Subgroup_ethnicity majority/caucasian_Alcohol use_Prevalence.
Comparison 1 Any parent/family intervention vs no intervention/standard care, Outcome 11 Subgroup_no weekly or heavy drinking_Alcohol use_Prevalence.
Comparison 1 Any parent/family intervention vs no intervention/standard care, Outcome 12 Sensitivity_RoB_Alcohol use_Frequency.
Comparison 1 Any parent/family intervention vs no intervention/standard care, Outcome 13 Subgroup_universal_Alcohol use_Frequency.
Comparison 1 Any parent/family intervention vs no intervention/standard care, Outcome 14 Subgroup_selective/indicated_Alcohol use_Frequency.
Comparison 1 Any parent/family intervention vs no intervention/standard care, Outcome 15 Subgroup_>12 months_Alcohol use_Frequency.
Comparison 1 Any parent/family intervention vs no intervention/standard care, Outcome 16 Subgroup_ethnicity minority_Alcohol use_Frequency.
Comparison 1 Any parent/family intervention vs no intervention/standard care, Outcome 17 Subgroup_ethnicity majority/caucasian_Alcohol use_Frequency.
Comparison 1 Any parent/family intervention vs no intervention/standard care, Outcome 18 Subgroup_no binge_Alcohol use_Frequency.
Comparison 1 Any parent/family intervention vs no intervention/standard care, Outcome 19 Sensitivity_RoB_Alcohol use_Volume.
Comparison 1 Any parent/family intervention vs no intervention/standard care, Outcome 20 Subgroup_universal_Alcohol use_Volume.
Comparison 1 Any parent/family intervention vs no intervention/standard care, Outcome 21 Subgroup_selective/indicated_Alcohol use_Volume.
Comparison 1 Any parent/family intervention vs no intervention/standard care, Outcome 22 Subgroup_>12 months_Alcohol use_Volume.
Comparison 1 Any parent/family intervention vs no intervention/standard care, Outcome 23 Subgroup_ethnicity_minority_Alcohol use_Volume.
Comparison 1 Any parent/family intervention vs no intervention/standard care, Outcome 24 Subgroup_ethnicity majority/caucasian_Alcohol use_Volume.
Comparison 1 Any parent/family intervention vs no intervention/standard care, Outcome 25 Subgroup_female only_Alcohol use_Volume.
Comparison 2 Family‐based and adolescent intervention vs intervention with young people alone, Outcome 1 Alcohol use_prevalence.
Comparison 2 Family‐based and adolescent intervention vs intervention with young people alone, Outcome 2 Alcohol use_frequency.
Comparison 2 Family‐based and adolescent intervention vs intervention with young people alone, Outcome 3 Sensitivity_RoB_Alcohol use_prevalence.
Comparison 2 Family‐based and adolescent intervention vs intervention with young people alone, Outcome 4 Subgroup_universal_Alcohol use_prevalence.
Comparison 2 Family‐based and adolescent intervention vs intervention with young people alone, Outcome 5 Sensitivity_RoB_Alcohol use_frequency.
Comparison 2 Family‐based and adolescent intervention vs intervention with young people alone, Outcome 6 Subgroup_universal_Alcohol use_frequency.
Comparison 2 Family‐based and adolescent intervention vs intervention with young people alone, Outcome 7 Subgroup_indicated_Alcohol use_frequency.
| Family/parent interventions compared with no intervention/standard care for prevalence of adolescent alcohol consumption | ||||||
| Patient or population: parents/children Settings: recruitment through schools (n = 11), communities (n = 6), paediatric emergency departments (n = 2), other health clinics (n = 2); referral by schools, the justice system, therapists, physicians, or parents (n = 1); street‐based recruitment (n = 1) or random digit dialling (n = 1); and delivery via resources sent home (n = 3); face‐face in schools, homes, or community venues (n = 14); or via the Internet or computer (n = 2) Intervention: parent interventions (positive parenting and communication and counselling sessions) Comparison: no intervention | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | No. of participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| Risk with no intervention | Risk with parent intervention | |||||
| Alcohol use prevalence Up to 4 years post intervention impact of family/parent interventions compared to control on the prevalence of alcohol consumption or drunkenness | Mean prevalence of lifetime alcohol use was 85%a | Mean prevalence of lifetime alcohol use in intervention groups was zero (0.16 lower to 0.16 higher) | 7490 | ⊕⊕⊝⊝ | Scores estimated using a standardised mean difference of 0.00 (95% CI ‐0.08 to 0.08) | |
| Alcohol use frequency Up to 4 years post intervention impact of family/parent interventions compared to control on the frequency of alcohol consumption | Mean number of drinking days in previous 90 days was 2.5c | Mean number of drinking days in intervention groups was 0.16 lower (0.42 lower to 1.1 higher) | 1855 (8 RCTs) | ⊕⊝⊝⊝ | Scores estimated using a standardised mean difference of ‐0.31 (95% CI ‐0.83 to 0.21) | |
| Alcohol use volume Up to 4 years post intervention impact of family/parent interventions compared to control on the volume of alcohol consumption or drunkenness | Mean number of drinks in the last 30 days among control groups was 0.83e | Mean number of drinks in intervention groups was 0.18 lower (0.34 lower to 0.00 higher) | 1825 (5 RCTs) | ⊕⊕⊝⊝ | Scores estimated using a standardised mean difference of ‐0.14 (95% CI ‐0.27 to 0.00) | |
| Adverse events | No studies reported this outcome | |||||
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence. | ||||||
| aWe have used results (mean scores and standard deviation) from Bauman 2002 to illustrate effect sizes in terms of the measures used in that study. This study was chosen for its use of common outcome measures and intervention approach, and low risk of bias. bDowngraded one level due to high or unclear risk of bias ratings in several domains; downgraded one level due to moderate heterogeneity that was explained only in part in subgroup analysis. cWe have used results (mean scores and standard deviation) from Winters 2012 to illustrate effect sizes in terms of the measures used in that study. This study was chosen for its use of common outcome measures and low risk of bias. dDowngraded one level due to high or unclear risk of bias ratings in several domains; downgraded two levels due to high heterogeneity that was not explained in subgroup analysis; downgraded one level due to imprecision of results, with a wide confidence interval (crosses ‐0.5 and crosses zero; therefore the true effect could be either a benefit or a harm). eWe have used results (mean scores and standard deviation) from Mason 2012 to illustrate effect sizes in terms of the measures used in that study. Although this study provides only small numbers and favours the control condition, it was chosen for the availability of mean and standard deviation derived from a common outcome measure and low risk of bias. fDowngraded one level due to high or unclear risk of bias ratings in several domains; downgraded one level due to a high probability of selective reporting bias, with the meta‐analysis potentially not representative of available studies (only 5 out 9 included studies were included in meta‐analysis). | ||||||
| Family/parent and adolescent interventions compared with adolescent only interventions for adolescent alcohol consumption | ||||||
| Patient or population: parents and children Settings: recruitment through schools (n = 5), community agencies (n = 2), or trauma centres (n = 1), and delivery via resources sent home (n = 3), or face‐face in schools, homes, or community venues (n = 5) Intervention: interventions involving both family/parent components and adolescent components delivered together or separately Comparison: interventions delivered to adolescents only with no family/parent component | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | No. of participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| Risk with adolescent interventions | Risk with addition of parent to adolescent interventions | |||||
| Alcohol use prevalence Up to 4 years post intervention impact of family/parent interventions compared to control on the prevalence of alcohol consumption or drunkenness | Mean prevalence of ever having had an alcoholic drink was 12.9%a | Mean prevalence of ever having had an alcoholic drink in the intervention groups was 0.27 lower (0.62 lower to 0.10 higher) | 5640 | ⊕⊝⊝⊝ | Scores estimated using a standardised mean difference of ‐0.39 (95% CI ‐0.91 to 0.14) | |
| Alcohol use frequency Up to 4 years post intervention impact of family/parent interventions compared to control on the frequency of alcohol consumption | Mean frequency of alcohol use in the previous 30 days was 1 dayc | Mean frequency of alcohol use in the intervention groups was 0.04 lower (0.09 lower to 0.02 higher) | 915 (4 RCTs) | ⊕⊝⊝⊝ | Scores estimated using a standardised mean difference of ‐0.16 (95% CI ‐0.42 to 0.09) | |
| Adverse events | No studies reported this outcome | |||||
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence. | ||||||
| aWe have used results (mean scores and standard deviation 0.68) from Reddy 2002 to illustrate effect sizes in terms of the measures used in that study. This study was chosen for its use of a common outcome measure and low risk of bias. bDowngraded one level due to high or unclear risk of bias ratings in several domains; downgraded two levels due to high heterogeneity that was not explained in subgroup analysis; downgraded one level due to imprecision of results, with a wide confidence interval (crosses ‐0.5 and crosses zero; therefore the true effect could be either a benefit or a harm). cWe have used results (mean scores and standard deviation) from Schinke 2004 to illustrate effect sizes in terms of the measures used in that study. This study was chosen for its use of a common outcome measure and low risk of bias. dDowngraded one level due to high or unclear risk of bias ratings in several domains; downgraded one level due to moderate heterogeneity that was explained only in part in subgroup analysis; downgraded one level due to imprecision of results, with a wide confidence interval (crosses ‐0.5 and crosses zero; therefore the true effect could be either a benefit or a harm) and a relatively small sample size. | ||||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Alcohol use_Prevalence Show forest plot | 12 | 7490 | Std. Mean Difference (Random, 95% CI) | 0.00 [‐0.08, 0.08] |
| 2 Alcohol use_Frequency Show forest plot | 8 | 1835 | Std. Mean Difference (Random, 95% CI) | ‐0.31 [‐0.83, 0.21] |
| 3 Alcohol use_Volume Show forest plot | 5 | 1825 | Std. Mean Difference (Random, 95% CI) | ‐0.14 [‐0.27, 0.00] |
| 4 Sensitivity_RoB_Alcohol use_Prevalence Show forest plot | 5 | 1733 | Std. Mean Difference (Random, 95% CI) | ‐0.12 [‐0.35, 0.11] |
| 5 Subgroup_universal_Alcohol use_Prevalence Show forest plot | 10 | 7133 | Std. Mean Difference (Random, 95% CI) | 0.02 [‐0.06, 0.11] |
| 6 Subgroup_selective/indicated_Alcohol use_Prevalence Show forest plot | 2 | 357 | Std. Mean Difference (Random, 95% CI) | ‐0.16 [‐0.36, 0.05] |
| 7 Subgroup_low intensity_Alcohol use_Prevalence Show forest plot | 6 | Std. Mean Difference (Random, 95% CI) | ‐0.01 [‐0.10, 0.08] | |
| 8 Subgroup_>12 months_Alcohol use_Prevalence Show forest plot | 11 | Std. Mean Difference (Random, 95% CI) | 0.00 [‐0.08, 0.09] | |
| 9 Subgroup_ethnicity minority_Alcohol use_Prevalence Show forest plot | 3 | 325 | Std. Mean Difference (Random, 95% CI) | ‐0.20 [‐0.42, 0.02] |
| 10 Subgroup_ethnicity majority/caucasian_Alcohol use_Prevalence Show forest plot | 9 | Std. Mean Difference (Random, 95% CI) | 0.03 [‐0.06, 0.11] | |
| 11 Subgroup_no weekly or heavy drinking_Alcohol use_Prevalence Show forest plot | 9 | Std. Mean Difference (Random, 95% CI) | 0.01 [‐0.12, 0.13] | |
| 12 Sensitivity_RoB_Alcohol use_Frequency Show forest plot | 5 | 1488 | Std. Mean Difference (Random, 95% CI) | 0.09 [‐0.24, 0.43] |
| 13 Subgroup_universal_Alcohol use_Frequency Show forest plot | 3 | 1090 | Std. Mean Difference (Random, 95% CI) | 0.18 [‐0.40, 0.75] |
| 14 Subgroup_selective/indicated_Alcohol use_Frequency Show forest plot | 5 | 745 | Std. Mean Difference (Random, 95% CI) | ‐0.65 [‐1.64, 0.33] |
| 15 Subgroup_>12 months_Alcohol use_Frequency Show forest plot | 8 | 1835 | Std. Mean Difference (Random, 95% CI) | ‐0.31 [‐0.83, 0.21] |
| 16 Subgroup_ethnicity minority_Alcohol use_Frequency Show forest plot | 3 | 1037 | Std. Mean Difference (Random, 95% CI) | ‐1.19 [‐2.83, 0.46] |
| 17 Subgroup_ethnicity majority/caucasian_Alcohol use_Frequency Show forest plot | 5 | 798 | Std. Mean Difference (Random, 95% CI) | 0.15 [‐0.13, 0.43] |
| 18 Subgroup_no binge_Alcohol use_Frequency Show forest plot | 7 | 1519 | Std. Mean Difference (Random, 95% CI) | ‐0.37 [‐1.01, 0.27] |
| 19 Sensitivity_RoB_Alcohol use_Volume Show forest plot | 4 | 1397 | Std. Mean Difference (Random, 95% CI) | ‐0.15 [‐0.32, 0.03] |
| 20 Subgroup_universal_Alcohol use_Volume Show forest plot | 3 | 1481 | Std. Mean Difference (Random, 95% CI) | ‐0.21 [‐0.32, ‐0.10] |
| 21 Subgroup_selective/indicated_Alcohol use_Volume Show forest plot | 2 | 344 | Std. Mean Difference (Random, 95% CI) | 0.06 [‐0.15, 0.27] |
| 22 Subgroup_>12 months_Alcohol use_Volume Show forest plot | 3 | 988 | Std. Mean Difference (Random, 95% CI) | ‐0.16 [‐0.35, 0.02] |
| 23 Subgroup_ethnicity_minority_Alcohol use_Volume Show forest plot | 3 | 1081 | Std. Mean Difference (Random, 95% CI) | ‐0.24 [‐0.36, ‐0.12] |
| 24 Subgroup_ethnicity majority/caucasian_Alcohol use_Volume Show forest plot | 2 | 744 | Std. Mean Difference (Random, 95% CI) | ‐0.01 [‐0.17, 0.15] |
| 25 Subgroup_female only_Alcohol use_Volume Show forest plot | 2 | 1053 | Std. Mean Difference (Random, 95% CI) | ‐0.25 [‐0.37, ‐0.13] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Alcohol use_prevalence Show forest plot | 4 | 5640 | Std. Mean Difference (Random, 95% CI) | ‐0.39 [‐0.91, 0.14] |
| 2 Alcohol use_frequency Show forest plot | 4 | 915 | Std. Mean Difference (Random, 95% CI) | ‐0.16 [‐0.42, 0.09] |
| 3 Sensitivity_RoB_Alcohol use_prevalence Show forest plot | 2 | 3891 | Std. Mean Difference (Random, 95% CI) | ‐0.61 [‐1.84, 0.63] |
| 4 Subgroup_universal_Alcohol use_prevalence Show forest plot | 3 | 5351 | Std. Mean Difference (Random, 95% CI) | ‐0.44 [‐1.08, 0.20] |
| 5 Sensitivity_RoB_Alcohol use_frequency Show forest plot | 3 | 832 | Std. Mean Difference (Random, 95% CI) | ‐0.21 [‐0.50, 0.08] |
| 6 Subgroup_universal_Alcohol use_frequency Show forest plot | 2 | 596 | Std. Mean Difference (Random, 95% CI) | ‐0.30 [‐0.68, 0.07] |
| 7 Subgroup_indicated_Alcohol use_frequency Show forest plot | 2 | 319 | Std. Mean Difference (Random, 95% CI) | 0.01 [‐0.21, 0.23] |
