Benefits of Incorporating the Strengthening Families Program Into Family Drug Treatment Court Services

Introduction

The opioid epidemic has become a public health crisis in the United States, disrupting entire family units (Brundage & Levine, 2019). Between 2009 and 2014, an estimated 8.7 million children aged 17 or younger had at least one parent with a substance use disorder (Lipari & Van Horn, 2017), and an estimated 548,000 children lived with an adult diagnosed with opioid use disorder specifically (Bullinger & Wing, 2019). Recent estimates suggest that on average, 55% of child welfare cases involve substance use disorders (ranging from 16% to 79%; Seay, 2015). Given the negative impact of substance use disorders on emotional and behavioral patterns in families (Lander et al., 2013), it is critical that community members, particularly Extension educators, are informed about effective programs for supporting families. Extension educators' existing networks, resources, and strengths-based models make them well positioned to support parents and children affected by the opioid epidemic. In the study reported here, we assessed the benefits of a parent education program delivered by Extension educators—the Strengthening Families Program (SFP)—for families struggling with substance misuse who were involved in family drug treatment court services.

Family Drug Treatment Courts

Family drug treatment courts (FTCs) are specialized courts for families involved in the child welfare system who also struggle with substance misuse. Most recent estimates show 493 FTCs operating in counties across the United States (Children and Family Futures, 2018). Specific services offered by FTC staff vary widely but share the common goal of "reduc[ing] maltreatment by treating the underlying substance use problem through the collaborative efforts of treatment professionals in child welfare, the courts, and substance abuse agencies" (Gifford et al., 2014, p. 1660).

Evaluations of FTC services suggest that participation leads to improved child welfare and family outcomes. Specifically, parents who successfully complete programs are more likely to be reunified with their children compared to nonparticipants (Burrus et al., 2011; Green et al., 2007). Further, children of FTC program graduates spend significantly less time in out-of-home placements and nonkinship foster care (Burrus et al., 2011; Worcel et al., 2008). Collaborations between FTC leadership and Extension educators offer a unique opportunity for supporting vulnerable families.

SFP

SFP is an evidence-based, whole-family parent education program that focuses on parenting skills, children's life skills, and family life skills. More specifically, parents and children work on communication skills, goal setting, behavior management, strategies for dealing with peer pressure, substance use, and positive family relationships. The focus of this article is on the SFP curriculum originally created in the 1980s for families with children aged 6–11 (Molgaard et al., 2000). Each meeting (occurring weekly for 14 weeks) includes a family meal, 1-hr concurrent sessions for parents and children separately, and a 1-hr family session with all family members.

Findings from effectiveness studies have demonstrated that SFP participation is associated with improvements in parenting skills and increases in protective factors (e.g., positive family functioning) and resilience factors in both community populations and families dealing with substance misuse (Kumpfer & Magalhães, 2018). Findings have also shown improvements in family reunification after child welfare involvement (e.g., Brook et al., 2012; Johnson-Motoyama et al., 2013).

To our knowledge, just one study has explored the potential benefits of SFP in a population of families participating in FTC services (Brook et al., 2015). Brook et al. found a greater likelihood of reunification and shorter times to reunification for families involved in FTC services (which included SFP) compared to families who received child welfare services-as-usual. A key limitation of their study, however, is that the authors did not assess the influence of SFP specifically, but rather the entire range of services offered by FTC staff. Findings were also limited to child welfare outcomes and did not explore factors such as positive parenting behaviors and family dynamics (e.g., family communication), which had been associated with beneficial child outcomes in previous evaluations of SFP effectiveness (e.g., Suchman et al., 2007).

Purpose

We undertook our study to describe the results of participating in SFP for families involved in services as part of an FTC from 2014 to 2018. Our primary research questions were as follows:

1. Do positive parenting behaviors increase through FTC clientele participation in SFP?
2. Do family organization and conflict improve through FTC clientele participation in SFP?

Methods

Data Collection and Participants

Extension educators leading the SFP sessions collected program data on participants between 2014 and 2018; these data were from seven total sessions and a total of 46 participating families. Data included demographic information from administrative records, results from "pre-post" retrospective SFP Parenting Surveys completed by parents, and results from surveys on program fidelity completed by independent observers. In 2018, our research team coordinated with Extension educators to retrieve the hard-copy data. We then entered the data electronically and subsequently cleaned and deidentified the data and transferred the data to a secure data server for analysis.

Program participants included 63 parents and 65 children. All families were eligible to participate due to their involvement with FTC services. Parents who attended initial SFP sessions but did not complete the program (n = 22) were excluded from analyses. Reasons for noncompletion included family scheduling conflicts, transportation issues, and parental personal choice. Parents who did not complete the program were not significantly different from parents who did relative to sex, race/ethnicity, or child age. The final sample included 41 parents.

Measures

Parent and Family Measures

Our research team developed scales internally to assess parenting characteristics and behaviors, as well as family dynamics. Scales derived from the SFP Parenting Survey (Kumpfer, 2015) included parental warmth (e.g., "I praise my child when s/he has behaved well," three items, pretest α = 0.79, posttest α = 0.82); positive discipline (e.g., "I use appropriate consequences when my child will not do what I ask," five items, pretest α = 0.79, posttest α = 0.70); stress management (e.g., "I handle stress well," four items, pretest α = 0.86, posttest α = 0.69); family organization (e.g., "We talk as a family about issues/problems," four items, pretest α = 0.82, posttest α = 0.79); and family conflict (e.g., "People in my family often yell or insult each other," four items, pretest α = 0.81, posttest α = 0.85). All items were scored 1 = seldom to 5 = almost always. A full list of items is in the appendix.

Control Variables

Control variables included child age; family zip code; and parent sex, race/ethnicity (Black or African American, Caucasian, Hispanic/Latino, Native American), marital status (single, married or partnered, divorced, separated/widowed), and education level (8th grade or less, 9th–11th grades, 12th grade or GED, beyond high school, some college, 2-year college graduate, 4-year college graduate, post-4-year college graduate).

Analysis

We used Stata 14 for multilevel modeling with robust standard errors. Multilevel modeling with robust standard errors allowed for testing changes in parenting measures over time, simultaneously accounting for clustering due to some parents' participating with partners in the same family (Raudenbush & Bryk, 2002). We ran a separate analysis for each parenting outcome and included all control variables. Prior to analysis, we created a pre-post variable representing scores for each parenting variable before participating in SFP and after participating in SFP. We determined evidence of a significant difference in each parenting variable between pretest and posttest scores via a statistically significant (p < .05) pre-post coefficient (i.e., the coefficient representing the difference between pretest and posttest scores).

Results

Descriptive Statistics

Participants mostly identified as Caucasian (75% Caucasian, 11% Black or African American, 11% Hispanic/Latino, 3% Native American) and unpartnered or single caregivers (50% single, 32% married or partnered, 2% divorced, 16% widowed/separated). Most participants were female (62%). Regarding highest level of education completed, 47% of participants had completed 12th grade or received a GED, 7% had completed some education beyond high school, and 46% had completed some college or attained a 2-year degree, a 4-year degree, or higher.

Table 1 shows descriptive statistics and correlations for all study variables. There were no significant differences in pretest or posttest outcomes with regard to parent sex, parent marital status, or family zip code. There were differences in postprogram stress levels with regard to parent race/ethnicity, F(4,22) = 4.03, p < .05, and in postprogram conflict levels with regard to parent education, F(6,28) = 3.66, p < .01. Parents identifying as Hispanic or Latino had significantly higher stress (M = 4.92, SD = .08) after SFP compared to parents identifying as Caucasian (M = 4.36, SD = .09), t(31) = −2.01, p < .05. Parents with an education of some college had significantly lower levels of conflict (M = 1.61, SD = .15) after SFP compared to parents with a high school diploma or GED (M = 2.11, SD = .20), t(36) = 2.04, p < .05.

Table 1.
Descriptive Statistics and Correlations Among Study Variables

Variable	1	2	3	4	5	6	7	8	9	10	11
1. Child age	—
2. Warmth pre	−.28	—
3. Warmth post	−.14	.63***	—
4. Discipline pre	−.01	.47**	.44**	—
5. Discipline post	−.10	.41**	.64***	.56***	—
6. Stress pre	−.12	.50**	.18	.67	.27	—
7. Stress post	−.10	.26	.35*	.34*	.50**	.55***	—
8. Organization pre	.05	.42**	.21	.80***	.40*	.68***	.23	—
9. Organization post	−.14	.30	.44**	.49**	.68***	.34*	.57***	.48**	—
10. Conflict pre	.33*	−.34*	−.26	−.48**	−.35*	−.58***	−.53***	−.46**	−.42**	—
11. Conflict post	.14	−.06	−.23	−.31	−.42**	−.31	−.61***	−.23	−.42**	.72***	—
M	7.87	4.23	4.75	2.10	2.97	3.72	4.40	3.04	4.11	2.26	1.78
SD	1.74	.78	.45	.74	.52	.87	.51	.99	.64	.93	.76
Range	5–12	0–5	0–5	0–5	0–5	0–5	0–5	0–5	0–5	0–5	0–5
Note. "Pre" = pretest; "post" = posttest. *p < .05. **p < .01. ***p < .001.

Parent Outcomes, Family Organization, and Conflict

Scores on all parenting and family outcome measures showed improvement between pretest and posttest scores (Table 2 and Figure 1). When controlling for child age, parent sex, parent marital status, parent race/ethnicity, parent education level, and family zip code, parents' average scores increased in warmth (.72 points, SE = .14), positive discipline (.86 points, SE = .13), stress management (.84 points, SE = .19), and family organization (1.15 points, SE = .22), changing by approximately half a standard deviation for all four scales. Scores in family conflict decreased on average by .65 points (SE = .18; β = −.38). The strongest improvements were in positive discipline (β = .56) and family organization (β = .55).

Table 2.
Multilevel Model Results: Changes in Parenting Outcomes, Family Organization, and Conflict Between Pretest and Posttest Scores

Variable	b	Robust SE	β	95% CI
Warmth	.72	.14	.50**	.44–.99
Discipline	.86	.13	.56***	.61–1.11
Stress management	.84	.19	.49**	.47–1.21
Organization	1.15	.22	.55***	.71–1.59
Conflict	−.65	.18	−.38***	−.99–−.30
Note. All analyses controlled for child age; family zip code; and parent sex, race/ethnicity, marital status, and education level. CI = confidence interval. ***p < .001.

Figure 1.
Pretest and Posttest Scores for Parenting and Family Variables

Note. Scores are unadjusted for covariates.

Program Fidelity

To help ensure confidence that the program was implemented as intended, we assessed program fidelity using an SFP-developed survey. Leaders self-rated their program facilitation and curriculum coverage (19 questions scored 1 = very poor, 5 = excellent). Independent observers attended six single sessions of each SFP series and rated leader performance (scored 1 = below average, 3 = above average), including regarding completion of material and participants' perceived understanding of material. Scores for program fidelity and facilitator effectiveness were consistently high. The mean rating for leaders' assessments of their own effectiveness was 4.06 (SD = .47), and observers' mean rating was 2.89 (SD = .26); r = .29, p < .01. The mean overall leader rating by observers was 2.94 (SD = .23), the mean overall completion of material to be covered was 2.53 (SD = .56), and the mean rating of participants' understanding of the material was 2.66 (SD = .54). These high scores inspire confidence that our findings are reflective of participants' receiving the intended SFP curriculum, not an unintentionally adapted version for families participating in FTC services.

Discussion and Implications for Extension

Our findings offer evidence that use of the SFP curriculum, with fidelity of program implementation, positively influences parents and families who are participating in FTC services. In our study, scores from parenting scales revealed increases in parental warmth, positive discipline, stress management, and family organization, along with decreases in family conflict as shown by pretest and posttest results. The strongest improvements were in positive discipline and family organization, a result likely stemming from the curriculum's focus on learning and practicing effective communication strategies. As discussed in other literature (e.g., Suchman et al., 2007), each of these positive parenting practices and family dynamics is linked to a plethora of beneficial outcomes for children, including improved emotional and psychological adjustment, and reduced maladaptive behaviors.

Prior work has demonstrated that communities view Extension professionals as playing an important role in alleviating the negative consequences of the opioid epidemic (e.g., Steen et al., 2019). The evidence from our study supports the findings that Extension professionals, in collaboration with FTC leadership, play an integral role in supporting high-risk families and can integrate existing stand-alone programs—such as FTC programming and SFP—to enhance program reach. Although it takes time to build long-term relationships between Extension educators and FTC leaders (e.g., judges, court staff, and social service staff), findings from our study offer promising evidence that these collaborations can be effective in supporting families. The addition of SFP to existing court services also provides an opportunity to tailor programming to the unique challenges families face amid the opioid epidemic and to leverage the expertise of Extension professionals and FTC leaders.

There are four key limitations of our study to note. First, parents completed surveys retrospectively. This approach follows methods used in previous studies of SFP but may not fully capture the changes families experienced over time (Betz & Hill, 2006). Second, families were receiving a broad range of services along with SFP. It was not possible to tease out the unique influence of SFP for our study; future work that includes a formal control group and involves pretest and posttest measures may more accurately capture the program's effects. Third, our study included parents only; future work that explores child perspectives and outcome data would further enrich this literature. Lastly, our study focused on SFP specifically, and there are many other Extension programs that may benefit families through Extension–FTC collaborations. Future work exploring these other types of programming would provide even more insights on best practices for forming successful collaborations to support families.

Conclusion

The results of our study suggest that SFP can be used to support families as they work through challenges amid the opioid epidemic. Extension professionals are well-positioned to support these families and can do so by leveraging existing networks, resources, and strengths-based models to offer effective programs. Additionally, Extension professionals can seek to partner with their local FTC program leaders to offer SFP to further improve family outcomes.

Author Note

We wish to thank the William T. Grant Foundation for supporting our work, as well as Laura Tach, Rachel Dunifon, and Anna Steinkraus for their leadership and guidance throughout the project.

Correspondence concerning this article should be addressed to Elizabeth Day. Email: ead255@cornell.edu

References

Betz, D. L., & Hill, L. G. (2006). Real world evaluation. Journal of Extension, 44(2), Article 2RIB9. https://www.joe.org/joe/2006april/rb9.php

Brook, J., Akin, B. A., Lloyd, M. H., & Yan, Y. (2015). Family drug court, targeted parent training and family reunification: Did this enhanced service strategy make a difference? Juvenile and Family Court Journal, 66(2), 32–52. https://doi.org/10.1111/jfcj.12028

Brook, J., McDonald, T. P., & Yan, Y. (2012). An analysis of the impact of the Strengthening Families Program on family reunification in child welfare. Children and Youth Services Review, 34(4), 691–695. https://doi.org/10.1016/j.childyouth.2011.12.018

Brundage, S. C., & Levine, C. (2019). The ripple effect: The impact of the opioid epidemic on children and families. United Hospital Fund. https://uhfnyc.org/media/filer_public/17/2c/172ca968-43aa-45f9-a290-50018e85a9d8/uhf-opioids-20190315.pdf

Bullinger, L. R., & Wing, C. (2019). How many children live with adults with opioid use disorder? Children and Youth Services Review, 104, 104381.

Bureau of Justice Assistance. (2004). National Drug Court Institute family dependency treatment courts: Addressing child abuse and neglect cases using the drug court model. U.S. Department of Justice.

Burrus, S. W. M., Mackin, J. R., & Finigan, M. W. (2011). Show me the money: Child welfare cost savings of a family drug court. Juvenile and Family Court Journal, 62(3), 1–14. https://doi.org/10.1111/j.1755-6988.2011.01062.x

Children and Family Futures. (2018). Family drug court inventory.

DeMarsh, J. P., & Kumpfer, K. L. (1985). Family-oriented interventions for the prevention of chemical dependency in children and adolescence. Journal of Children in Contemporary Society: Advances in Theory and Applied Research, 20(122), 117–151.

Gifford, E. J., Eldred, L. M., Vernerey, A., & Sloan, F. A. (2014). How does family drug treatment court participation affect child welfare outcomes? Child Abuse & Neglect, 38(10), 1659–1670. https://doi.org/10.1016/j.chiabu.2014.03.010

Green, B. L., Furrer, C. J., Worcel, S. D., Burrus, S. W. M., & Finigan, M. W. (2007). How effective are family treatment drug courts? Results from a 4-site national study. Child Maltreatment, 12, 43–59. https://doi.org/doi:10.1177/1077559506296317

Johnson-Motoyama, M., Brook, J., Yan, Y., & McDonald, T. (2013). Cost analysis of the Strengthening Families Program in reducing time to family reunification among substance-affected families. Children and Youth Services Review, 35(2), 244–252. https://doi.org/10.1016/j.childyouth.2012.11.008

Kumpfer, K. L. (2015). The Strengthening Families Program: Implementation and evaluation materials.

Kumpfer, K. L., & Magalhães, C. (2018). Strengthening Families Program: An evidence-based family intervention for parents of high-risk children and adolescents. Journal of Child & Adolescent Substance Abuse, 27(3), 174–179. https://doi.org/10.1080/1067828X.2018.1443048

Lander, L., Howsare, J., & Byrne, M. (2013). The impact of substance use disorders on families and children: From theory to practice. Social Work in Public Health, 28(3–4), 194–205. https://doi.org/10.1080/19371918.2013.759005

Lipari, R. N., & Van Horn, S. L. (2017). Children living with parents who have a substance use disorder. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/data/sites/default/files/report_3223/ShortReport-3223.html

Molgaard, V. K., Spoth, R. L., & Redmond, C. (2000). Competency training—The Strengthening Families Program: For parents and youth 10–14. U.S. Department of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention. https://www.ncjrs.gov/pdffiles1/ojjdp/182208.pdf

Raudenbush, S. W., & Bryk, A. S. (2002). Hierarchical linear models: Applications and data analysis methods (2nd ed.). Sage Publications.

Seay, K. (2015). How many families in child welfare services are affected by parental substance use disorders? A common question that remains unanswered. Child Welfare, 94, 19–51.

Steen, J., Robertson, M. N., Seitz, H., Downey, L., Hardman, A., & Buys, D. (2019). Addressing the opioid epidemic: Defining Cooperative Extension's role. Journal of Extension, 57(6), Article v57-6iw3. https://www.joe.org/joe/2019december/iw3.php

Suchman, N. E., Rounsaville, B., DeCoste, C., & Luthar, S. (2007). Parental control, parental warmth, and psychosocial adjustment in a sample of substance-abusing mothers and their school-aged and adolescent children. Journal of Substance Abuse Treatment, 32(1), 1–10. https://doi.org/10.1016/j.jsat.2006.07.002

Worcel, S., Furrer, C. J., Green, B. L., Burrus, S. W. M., & Finigan, M. W. (2008). Effects of family treatment drug courts on substance abuse and child welfare outcomes. Child Abuse Review, 17(6), 427–443. https://doi.org/10.1002/car.1045

Appendix
Parenting Survey Items

Scale	Cronbach's alpha	Items
Warmth	Pretest = 0.79 Posttest = 0.82	I praise my child when s/he has behaved well. I let my child know I really care about him or her. I am loving and affectionate with my child.
Discipline	Pretest = 0.79 Posttest = 0.70	I follow through with reasonable consequences when rules are broken. I reward completed chores with affirmations/praise, allowances, or privileges. I use appropriate consequences when my child will not do what I ask. I use clear directions with my child. I yell or shout when my child misbehaves (reverse scored).
Stress management	Pretest = 0.86 Posttest = 0.69	I handle stress well. I feel I am doing a good job as a parent. I feel happy about my life most of the time. I enjoy spending time with my child.
Organization	Pretest = 0.82 Posttest = 0.79	My child helps with chores, errands, and other work. We talk as a family about issues/problems and hold family meetings. We go over schedules, chores, and rules to get better organized. I talk to my child about his or her plans for the next day or week.
Conflict	Pretest = 0.81 Posttest = 0.85	People in my family often yell or insult each other. People in my family have serious arguments. We argue about the same things in my family over and over. We fight a lot in our family.