Journal of Ethnicity in Substance Abuse, 12:68–81, 2013 Copyright © Taylor & Francis Group, LLC
ISSN: 1533-2640 print/1533-2659 online
Family-Centered Interventions for Substance Abuse in Hispanic Communities
SHIRLEY N. SPARKS
Emerita, Western Michigan University, Kalamazoo, Michigan
ROSEMARY TISCH and MARY GARDNER
Prevention Partnership International, Saratoga, California
Treatment programs geared toward Hispanic culture are extremely rare, and programs involving the entire Hispanic family are virtually nonexistent. Two prospective studies test the hypothesis that a family-centered intervention is as effective with Hispanic families as it is with non-Hispanic families. First, the program (Celebrating Families!) was presented in English to non-Hispanic and Hispanic families. Second, the program was translated into Spanish and adapted to Spanish culture (¡Celebrando Familias!). Hispanic families were compared with non-Hispanic families in both studies. These studies indicate that a family-centered treatment model can be an effective treatment intervention for Hispanic clients.
KEYWORDS Hispanic, family, substance abuse intervention
Alcohol use patterns and the prevalence of alcohol-related problems vary among ethnic groups. Social and cultural factors, such as drinking norms and attitudes, and perhaps genetic factors may account for these differences (Galvan & Caetano, 2003). Caetano (2003) reviewed alcohol epidemiological evidence on health disparities across Whites, Blacks, and Hispanics. Compared with non-Hispanics, Hispanic men have higher rates of alcohol- related problems, intimate partner violence, and cirrhosis mortality. Hispanics face challenges as a racial/ethnic group that the traditional Euro-American
model of treatment does not address. Unfortunately, substance abuse serves a purposeful function for many Hispanics as a means of escape from the problems related to social, environmental, and political structures (Gallardo & Curry, 2009). Caetano (2003) further found that Hispanics, as well as the other groups, see treatment as an appropriate intervention to address alcohol problems and there is also support for prevention in the Hispanic community.
Schmidt, Ye, Greenfield, and Bond (2007) concluded that although Hispanics reported higher severity alcohol problems than non-Hispanics, they were less likely to have received treatment and multiple types of alcohol services and were more likely to cite economic and logistical barriers as reasons for not obtaining care. Hispanics have poorer outcomes in substance abuse treatment programs. However, there is little empirical evidence that explains the problems these individuals experience in treatment, and there are few studies on the use and effectiveness of mutual help groups among this population (Alvarez, Jason, Olson, Ferrari, & Davis, 2007).
ACCULTURATION/BIRTHPLACE STRESSES ON HISPANIC
FAMILIES IN THE UNITED STATES
Hispanic families are subject to various degrees of acculturation that affect all aspects of family life, including alcohol use. Acculturation is a process that leads to the adoption of cultural traditions and values of the host society by immigrant groups. Differences in patterns of substance abuse have been noted between highly acculturated Hispanics (those who identify with American culture) and lowly acculturated Hispanics (those who identify more with their culture of origin). Those Hispanics who were born in the United States are usually more highly acculturated than those who have immigrated. Thus, a cultural divide may exist between immigrant parents and their U.S.- born children. Low and high family cohesion levels appear to be especially problematic among Mexican adolescents who are trying to navigate two different cultural worlds. Although high family cohesion is often a characteristic of Mexican families, Mexican-heritage adolescents may view high family cohesion as a hindrance to their own independence. Alcohol misuse could be used by adolescents as a mechanism to reduce emotional distress caused by family tensions (Marsiglia, Kulis, Parsai, Villar, & Garcia, 2009).
A comprehensive study by Caetano, Vaeth, and Rodriguez (2012) examined the association of acculturation and birthplace as they relate to alcohol- related social problems. Alcohol-related social problems may be legal (e.g., drinking and driving), interpersonal (e.g., divorce), or job-related (e.g., loss of job). They are different in nature from those problems associated with alcohol dependence, such as inability to control alcohol intake or withdrawal symptoms. Social problems studied by Caetano, Vaeth, and Rodriguez were belligerence, police problems, accidents, health-related problems, problems with spouse, problems with one’s children, work-related problems, and financial problems. In their study of Mexican Americans, Puerto Ricans, South/Central Americans, and Cuban Americans, they found that the association between birthplace and problems is stronger than the association between acculturation and problems; those born in the United States have a higher rate of problems than those born abroad. Birth in the United States was also associated with a greater likelihood of reporting problems with one’s children among Mexican American women. The authors conclude that alcohol problems are highly prevalent among U.S. Hispanics, but they are not strongly associated with acculturation. The association between birthplace and alcohol-related social problems is stronger than between acculturation and alcohol-related social problems. Stress associated with minority status usually associated with lack of economic opportunities, and the stresses and discrimination that these groups all can have may, therefore, be a uniform factor linking birth in the United States and alcohol-related problems across Hispanic national groups (Caetano et al., 2012).
There is some evidence that substance abuse among Hispanics may be increasing, especially among adolescents (Vasquez, 2009). Markides, Krause, and Mendes de Leon (1988) examined the influence of acculturation into the larger society on alcohol consumption with a three-generation study of Mexican Americans in San Antonio, Texas. Within-family analysis showed that the alcohol consumption of members of the younger generation was associated with the consumption of their parents, particularly in the case of younger women.
Family Prevention Factors
King and Vidourek (2011) assessed factors associated with recent alcohol use in Hispanic students in 7th to 12th grade in Cincinnati schools. They found that frequent church attendance, getting good grades, and having parents and teachers frequently talk about and set and enforce rules regarding alcohol use were associated with decreased recent alcohol use. They concluded that ongoing parent, teacher, and school communication and the consistent setting and enforcement of rules should be encouraged, which indicates that family involvement is important in breaking the cycle of addiction.
In another study of prevention factors, Voisine, Parsai, Marsiglia, Kulis, and Nieri (2008) explored the effects of three types of parental influences on Mexican and Mexican American adolescents on alcohol, cigarette, and marijuana use and anti-drug norms: parental monitoring of the child’s whereabouts; degree of parental permissiveness; and the strength of parental injunctive norms discouraging substance use. Results showed that parental permissiveness and parental injunctive norms, particularly anti-drug injunctive norms, had the strongest effects on the substance use outcomes, but parental monitoring generally was not a significant predictor.
The prevention literature has given little attention to how parental influences affect substance use among Mexican origin adolescents, even though they form part of the largest ethnic minority group in the United States. A critical need exists for prevention programs for Spanish speaking families as the rate of placement for Hispanic children in foster care due to abuse or neglect is significantly higher than for non-Hispanics (Child Welfare Services Reports for California, 2008), with Hispanic parents disproportionately represented in the Dependency Court system. Studies indicate high rates of lifetime substance use and substance use disorders for youths in the foster care system (National Survey on Drug Use and Health, 2005).
A FAMILY CENTERED INTERVENTION MODEL
Several programs have been created to help individuals deal with substance abuse, but few programs have been designed to include substance abusers and their families. Currently, few studies have been done to evaluate the effectiveness of such programs and almost none have focused on the effect of substance abuse programs for Hispanic families.
The purpose of this article is to present two prospective studies of a family-centered program where at least one family member is in substance abuse recovery or the family lives in a high-risk community, with the focus on the effectiveness of the program in Hispanic communities. In the first study, the program was presented in English to both non-Hispanics and Hispanics together and changes were compared within the families between the two groups for parenting skills, family strength/resilience, parent observation of their children’s behavior, parent cognitive awareness, and level of alcohol use (Coleman, 2006). In the second study, the program was culturally adapted to Hispanic populations and was presented in Spanish to monolingual and limited-English, Spanish-speaking adults and in English to the bilingual children of the adults (Sparks, Tisch, Gardner, & Sparks, 2010). Results from these adult and child participants were compared with a previous study of the English version of the program presented to English-speaking participants for four areas of effectiveness: parenting skills, family strengths/resilience, parent observations of their children’s behavior, and level of cognitive understanding of substance abuse.
The Celebrating Families!™ Model
The Celebrating Families!™ (Tisch & Sibley, 2004) program for parents in early recovery and their children is a program created to help families deal with substance abuse issues and to help unify families affected by substance and child abuse. Celebrating Families!™ is currently being implemented in 53 sites in 20 states in the United States and in Canada. Celebrating Families!™ is distributed by the National Association for Children of Alcoholics (www.celebratingfamilies.net). It has been replicated in mul- tiple settings, including schools, community-based sites, dependency drug courts, child welfare organizations, and treatment facilities. It is the only program listed on the Substance Abuse and Mental Health Services Agency’s National Registry of Evidence Based Programs & Practices that engages all family members ages 3 years to adult in learning healthy living skills while addressing child maltreatment, family violence, and addiction/recovery issues (SAMHSA gov). Celebrating Families!™ was originally developed for families in dependency drug courts, where one or both parents are in early recovery and children have been removed due to abuse or neglect. The Celebrating Families!™ program uses a multi-family, skill building model to engage every member of the family, with the goal of breaking the cycle of chemical dependency.
The program has been successfully administered in English, with English evaluation instruments indicating a significant effect on family organization, including cohesion, communication, conflict, and strengths/resilience; positive parenting; parent involvement, skills, efficacy, supervision; and alcohol and drug use reduction. The evaluation design was a non-experimental pre- to posttest design. The design determined whether the families improved by the posttest. As the independent evaluators (Lutra Group, 2007) stated:
Celebrating Families!™ is based on recent research about brain chemistry, addiction, resilience and asset development. Parent and children’s sessions include skills training sessions on nutrition, feelings, anger management, problem solving, decision making, limit setting, and boundary setting (p. 6) ... . The outcomes results were very positive for parent and family outcomes ... Nine of the ten parenting and family outcomes (90%) were statistically significant...Taken as a whole, these results are very positive for this pilot group. The results suggest positive changes in the parenting skills of the parents and family rela- tionships that are beginning to have positive results in reducing problem behaviors in the children. (p. 15).
DESCRIPTION OF THE PROGRAM
The weekly format of the Celebrating Families!™ program remains consistent through all 16 sessions.
Session topics are organized into these underlying principles:
1. Establish trust (Sessions 1–6) breaking the unwritten family rules of Don’t Talk, Don’t Feel, and Don’t Trust.
2. Address substance abuse disorders (Sessions 7–9) and their impact on individuals and families.
3. Focus on applying skills (Sessions 10–13) and addressing Risk and Protective Factors in families with child maltreatment and substance abuse disorders.
4. Prepare for the conclusion of group and for supporting children (Sessions 14–16).
This education/support, multi-family skill building group model begins with a family meal with the facilitators. The family then goes to a 90 minute session with their age group on the week’s topic. The parents and children come together at the end for a 30-minute structured activity for the whole family. It is highly interactive, developed specifically for children of alcoholics/ addicts and their parents, many with learning differences.
STUDIES OF Celebrating Families!™ IN HISPANIC POPULATIONS
The success rate of Hispanic vs. non-Hispanic participants in Celebrating Families!™ (Coleman, 2006) was analyzed for study 1. The entire study is available at www.celebratingfamilies.net/evaluation_reports.htm. As mentioned above, Celebrating Families!™ was originally developed for families in Family Drug Court in Santa Clara County, California. Families were assigned to the program by the court without regard for ethnicity or language use. All participants voluntarily completed the Celebrating Families!™ evaluation.
The study used convenience sampling because participants were chosen from existing adult Celebrating Families!™ participants. Participants were 5 men and 31 women from different ethnicities, with at least one parent from each family identified as a substance abuser. Thirteen participants were Hispanic (35.1%), 15 were White (40.5%), and 7 were other minori- ties (18.9%).
The primary languages spoken by Celebrating Families!™ participants were English (n = 31, 83.8%) and Spanish (n = 4, 10.8%); 11 participants who identified themselves as Hispanic were English speakers. Mean participant age was 37.31 years (standard deviation [SD] = 10.037 years). Mean income was $33,600. Data were collected from 3 study sites where the Celebrating Families!™, program was presented in San Jose, California— House on the Hill (residential program for mothers with their children), Eastfield-Ming Quong (community center), and Friends Outside (for families with incarcerated family members). Birthplace was not recorded for the participants, but the Hispanic population of the county is majority Mexican.
The study used a pretest-posttest retrospective design to evaluate the effectiveness of Celebrating Families!™ The study used secondary data collected from program participants by program staff from 3 study sites all located in San Jose. The Parent Retro/Post Questionnaire, which consisted of 6 sections, was administered at the end of the program. A higher score indicated more positive outcomes on each scale except for section 4.
1. About Your Family—demographic questionnaire.
2. Parenting Scale—measured parenting ability in a variety of areas.
3. Overall Family Strengths/Resilience—measured family support, mental
health, and the ability of families to cope with challenges.
4. Parent Drug and Alcohol Use—measured the number of days within the
past 30 days that the parent used drugs or alcohol.
5. Parent Observations of Child’s Activities—allowed parents to measure the
observed behavior of their children.
6. How Often are You (Parent) Good at ... —measured parent’s social and
cognitive skills in relation to interactions with children and others in making personal decisions.
RESULTS FROM STUDY 1
The focus of this article is to compare significant improvement between Hispanics and non-Hispanics. Therefore, to report all results of the study is beyond the scope of this review. The findings indicated that all participants showed significant improvement at posttest and that Hispanics showed as much or more improvement as non-Hispanics in the following areas: parenting skills, drug and alcohol use, family strengths/resilience, parent observations of the children’s activities, and parents’ social/cognitive skills.
Parenting skills. Although there was significant improvement for Hispanics in the level of parenting skills when compared with the pretest score, there was not a significant difference for Hispanics when compared with non-Hispanics. The mean improvement was 1.13 (SD=.79) for Hispanics, 0.97 (SD=0.58) for other minorities, and 0.64 (SD=0.74) for Whites. There was no significant relationship between parenting skills and primary language spoken by participants, although participants who spoke Spanish primarily showed the greatest level of improvement. The mean improvement was .81 (SD = 0.72) for English speakers and 1.44 (SD = .79) for Spanish speakers.
Drug and alcohol use. There was not a significant difference for Hispanics for level of drug and alcohol use when compared with Whites and other minorities (F = 1.34, df = 2.32, p = .28). The mean improvement was .56 (SD=1.53) for Hispanics, .48 (SD=1.26) for other minorities, and .76 (SD = 1.94) for Whites. Participants who spoke Spanish primarily showed the greatest level of improvement. The mean improvement was .33 (SD = 1.59) for English speakers and 1.25 (SD = 2.5) for Spanish speakers.
Family strengths/resilience. There was a significant difference for Hispanics in the level of family strengths/resilience when compared with Whites and other minorities (F = 5.93, df = 2,31, p = .01). Post hoc analysis using the Scheffe Test indicated a significant difference for Hispanics in the level of family strengths/resilience when compared with Whites (p = .01). The mean improvement was 2.41 (SD=1.46) for Hispanics and 0.95 (SD = 0.83) for Whites. There was no significant relationship between level of family strengths/resilience and primary language spoken by participants (t = 1.33, df = 32, p = .19), although participants who spoke Spanish primarily showed the greatest level of improvement. The mean improvement was 1.45 (SD = 1.28) for English speakers and 2.33 (SD = .80) for Spanish speakers.
Parent observations of the children’s activities. There was not a significant difference for Hispanics in parent observations of their children’s activities when compared with non-Hispanics, nor was there a significant difference by primary language spoken.
Parents’ social/cognitive skills. There was significant improvement between pre- and posttest scores for level of parent social and cognitive skills (t = 7.39, df = 29, p = .001), but there was not a significant difference in that level for Hispanics when compared with non-Hispanics, although the result was close to significant (F = 2.8, df = 2.27, p = .08). A significant rela- tionship did not exists between level of parent social and cognitive skills and primary language spoken.
LIMITATIONS OF THE STUDY
One of the limitations of this study was the small sample size. In addition, there was a significant difference in the number of participants by gender: 31 women and 5 men. Also, the participants were not monitored during the administration of the questionnaires and many participants skipped questions or sections.
CONCLUSIONS FROM STUDY 1
All participants, including Hispanics, Whites, and other minorities, showed improvement in each of the five measures of effectiveness of Celebrating Families!™. There was no evidence of problems with cultural competency indicated by this study. Factors that could be related to differences in culture for Hispanics, such as socioeconomic status and primary language, were not shown to have a negative effect on outcomes for Hispanic participants in the program. This study revealed especially promising results in regards to Hispanics’ participation in Celebrating Families!™ The result that Hispanics showed more change in the Celebrating Families!™ program when compared with non-Hispanics suggests that a family-centered model, such as Celebrating Families!™, may be an excellent resource for Hispanic clients dealing with substance abuse.
¡Celebrando Familias!™ (Sparks et al., 2010) was analyzed for study 2. The results of study 1 and the need exhibited in Santa Clara County for a program for Hispanic families led to the creation of a family-centered model program provided in Spanish. ¡Celebrando Familias!™ (Tisch, Sibley, & Ramirez, 2009) was created for monolingual and limited-English, Spanish- speaking families affected by substance abuse and at high risk for abuse, neglect, and family violence, with extremely low income and educational levels. Children in these families are bilingual (speaking English and Spanish). Group leaders were all bilingual Spanish and English speakers and lived in the communities they served. Birthplace was not recorded, but the communities were a majority Mexican. The curriculum was translated into Spanish, culturally adapted, and piloted at three sites:
Latino Community Development Center, a substance abuse treatment center, in Oklahoma City, Oklahoma. Ten parents completed the parent satisfaction scale, 5 youth aged 8–12 years completed the youth satisfaction scale, and 3 youth aged 16–17 years completed the youth satisfaction scale.
EMQ-Families First (Dorsa Elementary School) in San Jose, California. This site had a mix of families referred from Dependency Drug Courts and others were from a high risk community without identified substance abuse problems. For those families, the program served as a primary prevention program. Thirty-one parents completed the Parent Satisfaction Scale, the Parents Skills Self-Assessment Scale, and the Cognitive True/ False Test; 11 youth aged 8–12 years completed the Youth Satisfaction Scale; 4 youth aged 13–17 years and 8 youth aged 8–12 years completed the Questions about You; 4 youth aged 13–17 years and 7 youth aged 8–12 years completed the Cognitive True/False Test; and group leaders completed Before and After Skills Observation Records on 11 11 youth aged 8-12 years and 4 youth aged 13-17 years.
The Mexican American Community Services Agency (MACSA) Collaborative in Gilroy, California. A community-based site for high risk families. Group leaders completed before and after Skills Observation Records on 11 children aged 3-7 years.
The entire study, including all of the questions in the scales, may be found at www.preventionpartnership.US.
The study design was a non-experimental pre to posttest design. This design primarily determines whether the families improved by the posttest. Evaluation instruments were completed at the conclusion of the 16-week program, for a total of 41 monolingual and limited-English, Spanish-speaking parents and 23 bilingual youth ranging in age from 8 to 17 years. Youth group leaders at all three sites evaluated youth skills before and after the program for 26 youth between ages 3–17 years. True-false (cognitive) questionnaires were completed by 11 youth and 31 adults to assess retention of the concepts taught in the program.
RESULTS FROM STUDY 2
Quantitative results. The success of the program as reported by the participants is comparable with the English version based on group leaders’ evaluations of the 26 youth participants and pre to posttest evaluation instruments completed by 64 participants, elementary age children through adults.
Results were consistent with the findings of the English version (Lutra Group, 2007). Adults reported significant satisfaction with the program. Child care was very important to parents’ willingness to attend. Results were also consistent with the Lutra Group (2007) findings for Celebrating Families!™ for English speakers, with parents also indicating a significant effect on family organization, cohesion, communication, conflict solving, strengths and resilience; positive parenting; parent involvement; improvement in parenting skills; and alcohol and drug use reduction. Group leaders for youth observed significant positive changes, with 96%–99% confidence levels. Youth were less satisfied with the program, and they reported fewer changes in themselves and their parents than the group leaders did. Cognitive scores for the factual material were lower for youth than for adults.
Qualitative results. In addition to quantitative evaluation, qualitative evaluation provides additional data and insight. Responses to open-end questions by the parents about the effect of the program were highly positive. Parent satisfaction instruments contained the following sample of open-ended questions:
1. How did ¡Celebrando Familias! help your family deal with alcohol and drugs?
“If I abuse alcohol, my children are likely to do the same.”
“If there is an alcoholic in the family, all the family suffers from alcoholism.” “It is important that the manner in which I respond to and attempt to help a person that may have this addiction, not be oppositional.”
2. What are the two most important things you will take away from ¡Celebrando Familias!?
It is very important to communicate loving words to our children (numerous responses).
Relaxation exercises (numerous responses).
How to address my children when they need attention. How to encourage them daily (numerous responses).
“First of all to know how to listen.”
How to control my anger (numerous responses).
“That others should respect our bodies and not touch us inappropriately. ”
3. What are the two most important things your children will take away? “My children told me ‘We need to eat together just like we did in ¡Celebrando Familias! program. If not, we’re not family!’”
“The importance of self-control.”
Group leader responses. A focus group of group leaders from EMQ-FF Addiction Prevention Services (Dorsa School site) and MASCA Collaboration met after the Spring 2009 pilot of groups. They were asked “What is one thing you will always remember from your group?” Answers included:
A single mom of a third grade student with behavior and social issues told her story of drug use while pregnant
and as a young mother. Tearfully, she said “if I’d known then what I have learned through
¡Celebrando Familias!, things would have been different!”
The incredible community response and family commitment!
The amazing turnout of fathers and their commitment! “Never as a facilitator had I had so many dads in my class!”
A Mom asking, “What is an alcoholic?” After the explanation, her response of “My dad is an alcoholic!”
A Mom saying, “I hug my kids and tell them I love them now. I don’t know why I didn’t do it before ... perhaps I was embarrassed, but not anymore!”
Serenity prayer with all 50+ participants in circle – not even fitting in the auditorium!
Doing the relaxation exercise with the young children and parents. When one of the children leads the relaxation exercise.
Reports of increased communication in family “guess what, my dad talked to me!”
Children’s sharing during family time. “They actually did learn”.
Kids motivating parents to keep coming back!
Kids educating family members about the term chemical dependency. They WANTED to use the “big word”.
Limitations of study 2. Questionnaires varied by site and language (all Spanish, all English, and mix of Spanish and English). Of the two sites where youth completed evaluations, youth received the youth program in Spanish at one site and in English at another. However, when youth joined the adults for group activities, only Spanish was used at both sites. Evaluators were unable to determine the number of sessions individuals attended and how attendance was related to reported behavioral changes or material learned (dose effect) because evaluation questionnaires were confidential. This analysis should be considered as prospective due to the small number of participants.
This article reviewed the evidence in two small prospective studies that a family-centered intervention model (i.e., Celebrating Families!™) that has been successfully administered in English to English-speaking families can produce comparable results with Hispanic families. Results of both studies indicate that the model is as effective for Hispanic families as it is for non-Hispanic families and that, in many instances, even more changes were made within the Hispanic families. Both studies suggest strongly that success with the program does not depend on ethnicity of Hispanic or non- Hispanic families, nor does it correlate with the preferred language (Spanish or English) of the participants in the program. Results were positive when the program was presented in English to bilingual Hispanic families and were positive when presented to Spanish-speaking families in Spanish. The program was enthusiastically received by both English- and Spanish- speaking participants, as indicated by satisfaction scores in both studies. Results were compromised by the small sample sizes and by the lack of consistency in the pre- and posttest questionnaires. However, in general the only negative results were found in the children’s questionnaires on the cognitive material, which may mean that the children did not attend the sessions in which it was presented or that their English skills were not sufficient. The parents got it and many of the children did not. However, the qualitative statements contributed by program staff support the probability that changes did occur with the children. These studies strongly suggest that a family-centered program model, such as Celebrating Families!™ and ¡Celebrando Familias!, can be an effective intervention for substance abuse for Hispanic clients.
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