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Adolescent Health, Medicine and Therapeutics 2014:5 127–142
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REVIEW
open access to scientific and medical research
Open Access Full Text Article
http://dx.doi.org/10.2147/AHMT.S48057
Family support programs and adolescent
mental health: review of evidence
Emily S Kuhn
Robert D Laird
Department of Psychology,
University of New Orleans,
New Orleans, LA, USA
Correspondence: Robert D Laird
Department of Psychology, GP 2001,
University of New Orleans,
New Orleans, LA 70148, USA
Tel +1 504 280 5454
Fax +1 504 280 6349
Email rlaird@uno.edu
Abstract: Family support programs aim to improve parent wellbeing and parenting as well
as adolescent mental and behavioral health by addressing the needs of parents of adolescents
experiencing or at risk for mental health problems. Family support programs can be part of the
treatment for adolescents diagnosed with mental or behavioral health problems, or family support
programs can be delivered as prevention programs designed to prevent the onset or escalation
of mental or behavioral health problems. This review discusses the rationale for family support
programs and describes the range of services provided by family support programs. The primary
focus of the review is on evaluating the effectiveness of family support programs as treatments
or prevention efforts delivered by clinicians or peers. Two main themes emerged from the review.
First, family support programs that included more forms of support evidenced higher levels of
effectiveness than family support programs that provided fewer forms of support. Discussion
of this theme focuses on individual differences in client needs and program adaptions that may
facilitate meeting diverse needs. Second, family support prevention programs appear to be
most effective when serving individuals more in need of mental and behavioral health services.
Discussion of this theme focuses on the intensity versus breadth of the services provided in pre-
vention programs. More rigorous evaluations of family support programs are needed, especially
for peer-delivered family support treatments.
Keywords: intervention, parent, mental and behavioral health
Introduction
Many prevention and treatment approaches that have demonstrated effectiveness
in promoting adolescent mental and behavioral health are family-centered.1 The
effectiveness of family-centered programs suggests the importance of family factors in
contributing to and protecting against adolescent behavioral and emotional problems.
Family-centered inventions are often implemented as support programs, and family
support programs will be the focus of this review. Family support programs aim to
improve parent wellbeing, parenting, and adolescent mental and behavioral health by
addressing the needs of parents of adolescents with mental health problems2 or at risk
for mental health problems.
In this review, we first discuss the rationale for providing family support
programs in adolescent mental health. Next, we provide an overview of the common
components of family support programs in adolescent mental health and then discuss
the modes through which family support programs are delivered. Evidence of the effec-
tiveness of family support treatment and prevention programs is reviewed for several
different typologies based on components and delivery method. This review aims to
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Kuhn and Laird
complement the more detailed descriptions and reviews of
specific programs that are available elsewhere.2,3
Importance of and rationale
for family support programs
Approximately 20% of adolescents aged 12–17 have mental
health problems.4 Adolescents with mental health problems
are more likely than other adolescents to engage in risky
behaviors and to experience other negative consequences.5
Adolescent mental health problems also negatively affect
adolescents’ families.4,6–9
According to ecological theories,10 individual develop-
ment occurs within the context of multiple progressively
larger socialization spheres. The central sphere of influence is
the everyday environment the person encounters – particularly
the family. Broader systems of social institutions – which can
include health services and family support programs – can
affect the development and mental and behavioral health of
the individual and the family. Family support programs can
provide parents with the resources and support to effectively
interact with their adolescents and perform their parenting
responsibilities.10
Although poor family function is not required for
adolescents to experience mental health problems, and
adolescent mental health problems do not inevitably lead
to family dysfunction, poor family functioning is robustly
linked to poor adolescent mental health. Adolescents’
mental health problems place a burden on families and can
be a source of family distress.4,6–9 Higher levels of parental
psychopathology, higher levels of parental stress, poor
parenting practices, higher levels of parent–adolescent
conflict, and lower levels of perceived family support
are linked with higher levels of adolescent emotional,
social, and behavioral problems.7,8,11–15 The link between
family functioning and adolescent mental health is likely
bidirectional and transactional. In any given family, poor
family functioning may initially be a contributor to or con-
sequence of poor adolescent mental health. However, over
time, the two are likely to become linked through numerous
transactions such that worsening mental health problems
undermine family functioning and worsening family func-
tioning exacerbates adolescent mental health problems.
Regardless of whether family distress is a contributor to or
consequence of adolescent mental health problems, family
support programs have the potential to improve adolescent
mental health by reducing family distress.
In line with ecological theories, family support programs
acknowledge the impact of the family on the development
of adolescents with mental and behavioral health problems
and recognize that families need support. The goals of family
support programs are to reduce both the adolescents’ mental
health problems and the adverse consequences of adolescents’
mental health problems experienced by families. As such,
impacts on parents and adolescents both provide evidence
of the effectiveness of family support programs.
Characteristics of family
support programs
Family support programs differ in program delivery method,
in whether the program seeks to function as a prevention or
treatment program, and in program characteristics. Family
support programs may be delivered by either professionals,
parent peers, or by a professional/peer team.2 Clinician-led
models are typically delivered by master’s or doctoral-level
clinicians and psychologists,2 but they may also be delivered
by school personnel such as teachers.3 Peer-led programs
are provided by parents or veteran parents to parents or
caregivers.2 Team-led models include a parent peer and a
professional/clinician.
Prevention programs aim to reduce the likelihood of
new cases of a disorder by altering underlying mechanisms
implicated in the development and maintenance of the
disorder. Prevention is distinct from – but complementary
to – treatment in their common goal of reducing the burden
of mental and behavioral health problems.16 Treatment occurs
when an individual who suffers from a disorder receives
services in order to experience relief from the disorder.16
Prevention services are offered to individuals who do not
meet criteria for a disorder, but the goal is to reduce the
likelihood of developing a disorder in the future. Given
that treatment and prevention programs may differ in the
populations they serve and in specific program goals and
methods, evidence of the effectiveness of treatment and
prevention programs will be reviewed separately.
Many family support programs share common components,
which have been aggregated and organized into five major cat-
egories: instructional, informational, advocacy, emotional, and
instrumental supports.2 These components distinguish fam-
ily support programs from other family-centered services.17
Instructional support includes teaching parents skills to
effectively manage their adolescent’s behavior, engage in
self-care practices including effective coping strategies, and
effectively communicate with their family.2 Instructional
support is designed to develop parents’ skills for effective
family management and for attending to personal wellbeing.
Informational support includes the provision of information
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Family support programs
about mental health problems, intervention options, and
adolescent development.2 The goal of informational support
is to increase understanding of mental health problems to set
the stage for treatment and better management of behavioral
and mental health problems. Advocacy supportive services
typically aim to empower parents by providing information
about parental rights and resources and training parents in
areas such as assertiveness, communication, goal setting,
and record keeping, which can help parents advocate for their
adolescent’s services.2 Emotional support typically is provided
via the opportunity to discuss issues, share experiences and
insight in a group format. Some clinician-led family support
programs provide the opportunity to discuss issues one-on-one
with a clinician.18 Regardless of delivery format, the goal of
emotional support is to enhance social connection and sup-
port, and to decrease feelings of isolation and helplessness.
Instrumental support services incorporate broader supportive
networks by linking families to concrete community-based
resources such as childcare services, transportation services,
and social services agencies.2 Encouraging families to utilize
the natural resources of their communities is beneficial for
maintenance of positive gains made while receiving family
support services.
Review criteria
This review updates and synthesizes prior reviews,2,3 but
concentrates on family support prevention and intervention
programs delivered or evaluated with a focus on adolescence.
Family support program evaluations with published outcome
data relevant to mental and behavioral health and functioning
were identified from previous reviews and by a literature
search of studies published from 2009 to 2014 that cited
previous reviews. We identified one new family support
intervention19 and updated the findings for several programs
with studies published since the earlier reviews.20–23
Effectiveness of family support
treatment programs
Many family support programs combine one or more of the
five components, but the particular combination of components
varies as a function of how the support program is delivered.
Most family support treatment programs are clinician-led. For
this review, clinician-led programs were divided into three
groups that differ in program components. Among clinician-led
programs, the combination of instructional and informational
support is most common with a second group of programs
adding advocacy to instructional and informational support.
The final group of clinician-led programs combines emotional
support with either instructional or informational support.
Clinician-led interventions that did not include one of the
most commonly identified groupings of program components
(eg, clinician-led programs with only one form of support, or
with all forms of support) were excluded from this review.
There were too few peer-led or team-led programs to further
divide those delivery categories based on components. The
sections that follow summarize the evidence of effectiveness
of family support treatments for clinician-led, peer-led, and
team-led delivery methods.
Clinician-led with combined instructional
and informational support
The clinician-led family support programs included in this
review are described in Table 1. The majority of clinician-led
programs combined instructional and informational support.
Caregiver outcomes included improvements in24,25 as well as
null26 and non-superior effects on25 mental health and stress.
Beneficial findings included improved parental self-esteem,
more positive cognitions regarding the child,24 and increased
participation in27 and satisfaction with the treatments.24,28
Regarding child outcomes, family support programs that
combined instructional and informational components yielded
benefits such as reductions in various symptoms of anxiety dis-
orders at post-treatment and follow-ups.26,28 Two studies showed
non-superior (ie, equivalent) effects on behavioral problems
relative to non-family support comparison29 and control25 condi-
tions. One study found that family support alone is as effective
as combined family support and medication and medication
alone conditions for ameliorating child internalizing problems.30
Additionally, family support programs with instructional and
informational components were associated with superior effects
on reducing child anxiety disorder diagnoses among children
of parents with anxiety disorders.29,31
In sum, clinician-led programs that combined instruc-
tional and informational support yielded mixed results.
Outcomes included some benefits on caregiver mental health
and child internalizing problems, as well as some null and
non-superior effects relative to comparison and control
conditions. Evidence suggested that children at higher risk
for anxiety – due to having parents with anxiety disorders –
may especially benefit from family support programs with
instructional/informational components.29,31
Clinician-led with combined instructional,
informational, and advocacy support
Clinician-led programs that combined instructional,
informational, and advocacy support were the second most
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Table 1 Clinician-led interventions
Program, source Sample demographics Design Relevant ndings
Informational and instructional support
Individual or group cognitive behavioral
family therapy (CBFT)26
n=77. Youth were primarily female; average
age 12 years
RCT. Pre-/post-treatment, 3- and
6-month follow-ups
No signicant effects on caregiver depression and stress.
Reduced child obsessive-compulsive disorder symptoms
and severity
Child behavior therapy + parent
anxiety management31
n=67. Youth were primarily male; average
age 9 (range 7–14)
RCT. Pre-/post-treatment, 12-month
follow-up
Parent anxiety management component enhanced short-
term efcacy of child behavior therapy for reducing
anxiety diagnoses among youth with an anxious parent
Maternal Stress Coping Group24 n=62. Youth were primarily white, male;
average age 10 (range 5–13)
RCT. Pre-/post-treatment, 5-month
follow-up
Improvements in parent depressive symptoms, self-
esteem, and reduced negative cognitions about the child.
Treatment satisfaction
FCBT29 n=161. Youth were primarily white,
male; average age 10 (range 7–14)
RCT. Pre-/post-treatment, 1-year follow-up Reductions in child anxiety disorder
diagnoses, similar to non-parent-
support individual CBT. FCBT yielded
superior effects among children of two
parents with anxiety disorders
A community-based aggression
management program25
n=123. Youth were primarily male; average
age 9 (range 7–11)
RCT. Pre-/post-treatment Although not superior to control, decreased child
behavioral problems and parental stress
Evidence-based engagement strategies27 n=109 parents. Youth were primarily black,
female; average age 10 (range 1–15)
RCT. File reviews Greater participation in intake and subsequent services
Time for a Future30 n=73. Youth were primarily female; average
age 15
RCT. Pre-/post-treatment, 6-month
follow-up
Family support alone yielded statistically signicant
improvements in depression, anxiety, and suicidal
ideation, similar to sertraline medication and combined
family support + sertraline
FRIENDS (a family-based group
cognitive behavioral treatment)28
n=71. Youth were primarily female, Australian;
average age 7 (range 6.5–10 years). FRIENDS
has a version for adolescents, ages 12–16
RCT. Pre-/post-treatment, 12-month
follow-up
More children in FRIENDS were diagnosis-free compared
to children in control conditions. High parent and child
treatment satisfaction
Informational, instructional and advocacy support
Trauma-focused cognitive behavioral
therapy32
n=229. Youth were primarily white, female;
average age 11 (range 8–14)
RCT. Pre-/post-treatment, 6- and
12-months follow-up
Improvements in parent depression, distress,
and parenting skills. Reduced child symptoms of
posttraumatic stress disorder, depression, behavioral
problems, and problematic cognitions
Individual and multi-family
psychoeducation34
n=9–35.Youth ages 8–11 1) Pre-/post-treatment evaluations,
2) pre-/post-treatment evaluations,
and 3) RCT. Pre-/post-treatment,
6-month follow-up
1) Increased knowledge about mood
disorders, decreased expressed emotion;
2) increased positive behaviors and decreased
negative behaviors, high satisfaction;
3) increased parental knowledge about mood
disorders, increased child-reported parental
social support, increased efcacy in obtaining
mental health services
The Parent Education and Skills
Training Group35
n=107 parents. Youth were primarily male;
average age 14 (range 12–17)
Pre-/post-treatment evaluations Improvement in child behavior, parenting skills, reduced
parent-child conict, high parent satisfaction
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Family support programs
Child and family focused cognitive
behavioral therapy, aka The Rainbow
Program36
n=34. Youth were primarily white, male, of
middle-class socioeconomic status; average
age 11 (range 5–12)
Exploratory pre-/post-treatment
feasibility study
Reductions in pediatric bipolar disorder symptoms and
severity; high parental satisfaction with treatment
Emotional and informational or emotional and instructional support
STEPP (Strategies to Enhance Positive
Parenting) Program37
n=120. Youth were primarily white, male;
average age 7 (range 5–12 years)
RCT. Pre-/post-treatment, 3-month
follow-up
Initial improvements in parent mental health and stress,
child oppositional deant disorder symptoms, increased
involvement in treatment
Family group psychoeducation40 n=25. Youth were average age 14 RCT. Pre-/post-treatment Weight gain associated with both the family support
treatment (family group psychoeducation), and family
therapy. No change in psychological functioning
Family-based education, support, and
attention29
Same sample and design as noted for FCBT
(listed in this table under Informational and
Instructional Support)
See FCBT Family-based education, support, and attention was less
effective than FCBT in terms of reducing child anxiety
disorder diagnoses
Psychoeducation and support group
intervention for bereavement38
n=52 families (75 children). Youth were primarily
white, female; average age 10. This intervention
targets youth, ages 6–15 years
RCT. Pre-/post-treatment Reduced anxiety and depressive symptoms. No change in
children’s posttraumatic stress or social adjustment. No
change in parent depression
Educational and support group for
parents with schizophrenic adolescents39
n=32 parents. Youth were primarily male;
average age 19
Pre-/post-treatment evaluations.
Qualitative analysis
No increases in knowledge about schizophrenia;
increased ability to manage the adolescent
Abbreviations: CBFT, cognitive behavioral family therapy; FCBT, family cognitive behavioral therapy; RCT, randomized controlled trial; CBT, cognitive behavioral therapy.
common type of clinician-led program. Among clinician-led
programs that combined instructional, informational, and
advocacy support, beneficial caregiver outcomes included
reductions in distress,32,33 and aversive behavior34 as
well as improvements in parenting skills,32,33,35 parenting
confidence,35 and increased knowledge regarding the child’s
disorder.34 Additionally, some studies reported high levels
of caregiver satisfaction with the treatment.34–36 Positive
child outcomes included significant decreases in mental
and behavioral health problems,32,33,35,36 reduced problematic
cognitions,32,33 and increased parental social support.34 One
study also reported high levels of child satisfaction with the
treatment.34 Clinician-led programs that combined instruc-
tional, informational, and advocacy support yielded favorable
results and were linked to improvements in caregiver’s mental
health, parenting knowledge and skills, as well as benefits
for children’s mental and behavioral health.
Clinician-led with a combination
of either emotional and instructional
or emotional and informational support
A minority of clinician-led programs included emotional
support combined with either instructional or informational
support. These programs were associated with null effects37
and initial improvements – that were not maintained at 3-month
follow-up37 – on parental mental health. Although parents
did not experience increased knowledge about the child’s
disorder,39 they exhibited increased involvement in treatment.38
Child outcomes were also mixed and included initial but non-
maintained improvements in behavioral problems,37 as well
as reductions38 and null effects on mental health and social
adjustment.38,40 Additionally, family support programs that
combined emotional support with either informational or
instructional support evidenced non-superior effects versus
comparison non-family-support interventions in one study,40
and weaker effects than a family support intervention that
combined informational and instructional support.29 Evidence
for clinician-led programs that emphasized emotional support
combined with either instructional or informational support is
mixed, with positive and null effects, as well as equivalency but
non-superiority or weaker effects relative to a comparison non-
family support intervention and a family support intervention
with different combinations of support components.
Peer-led
Peer-led programs were the second most common family
support service delivery model after clinician-led programs.2
The peer-led family support programs included in this review
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Kuhn and Laird
are described in Table 2. Caregiver outcomes included
improved mental health23 and increased self-care,22 but one
study found no differences in parental strain.41 One study
reported enhanced knowledge regarding mental health
and treatment,23 but another study reported no effect of the
program on knowledge of community resources or court
knowledge.19 Two studies reported increased caregiver
empowerment,22,42 and one study reported no differences in
caregiver empowerment.41 One program was more effective
among highly strained parents.20,21 Other caregiver outcomes
included improvements in select aspects of communication22
and treatment satisfaction.19,23 Peer-led programs yielded little
to no evidence of effectiveness for youth’s behavioral, emo-
tional, and academic functioning.20,21,41,42 While veteran par-
ents may serve as an important source of support for parents,2
there was inconsistent evidence of benefits from these pro-
grams for caregiver mental health and empowerment, and
the effects on child functioning were largely null.
Team-led
Team-led programs were a relatively rare model of service
delivery. Team-led family support programs included in
this review are described in Table 3. Beneficial caregiver
outcomes included increases in caregiver knowledge about
mental health services and increased self-efficacy regarding
the ability to acquire mental health treatment for the child.43
However, several studies reported no effect or non-superior
effects of the team-led family support treatments relative to
comparison treatments for parental outcomes such as care-
giver involvement in the child’s mental health services, parent
problem-solving skills, coping skills, or perceived social sup-
port. In terms of child outcomes, one study showed reductions
in child disruptive behavior, while another study showed non-
superior effects of the team-led family support intervention
relative to comparison treatment on child behavior. In sum,
although team-led treatment studies showed some positive
effects on caregiver outcomes, child outcomes were more
mixed, and there was minimal evidence demonstrating the
superiority of team-led family support programs over com-
parison treatments.
Treatment effectiveness summary
Overall, treatment effectiveness varied by service delivery
model. Clinician-led and team-led models often were
Table 2 Peer-led programs
Program, source Sample demographics Design Relevant ndings
Parent Empowerment
Program41
n=124 low-income minority parents RCT No differences in parents’ service self-
efcacy, empowerment, or strain. No
impact on child emotional or
behavioral functioning
EPSDT Family
Associate Program42
n=239 families. Youth were primarily
white, male; ages 4–7 years; from
households with annual incomes of less
than $10,000. This program targets
parents of youth, ages 4–18 years
Quasi-experimental. Pre-/
post-treatment
Increased caregiver empowerment
concerning family issues and the
children’s services. No changes in
child behavior problems
Parent Connectors20,21 n=115 and 128. Youth were primarily
male, black, of low socioeconomic
status; average age ∼14 years
1) Proof of concept study
using random assignment,
2) RCT. Pre-/post-treatment
Intervention more effective among
highly strained parents. Little to no
evidence of effectiveness for youth;
improved youth school functioning
but not academic functioning
NAMI Basics Program22 n=82. Youth were primarily male;
average age 10; parents were primarily
white. NAMI Basics targets children
and adolescents
Pre-/post-treatment
evaluations
Improvements in parent
empowerment and self-care.
Reductions in inammatory/incendiary
communication but no improvement
in positive/afrming communication
Juvenile Justice 101
(JJ 101)19
n=111. Sample was primarily female,
and white-non-Hispanic. JJ 101 targets
juveniles
Post-treatment evaluation Most participants endorsed satisfaction
but denied increased knowledge of
community resources. No signicant
effect on court knowledge
Screening, Education,
and Empowerment23
n=24, but eight mothers (others were
peer advocates and supervisors). Youth
were primarily Hispanic, male; average
age ∼9 years
Feasibility study with post-
treatment evaluation
Parents were primarily satised with
the intervention and perceived it as
relevant. Perceived benets included
enhanced knowledge about depression
and treatment, and improvement in
mental health
Abbreviations: RCT, randomized controlled trial; EPSDT, Early and Periodic Screening, Diagnosis and Treatment Program; NAMI, National Alliance on Mental Illness.
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Family support programs
evaluated using experimental designs and, most importantly,
randomized controlled trials.2 In contrast, peer-led programs
were less rigorously studied, and the research evidence
regarding their effectiveness was weak. Clinician-led pro-
grams yielded positive benefits on caregiver mental health,
parenting knowledge, and parenting strategies, as well
as improvements in child mental and behavioral health.
However, there were also some null effects and lack of
evidence of superiority of clinician-led programs relative to
comparison/control conditions. Team-led treatments were
associated with some benefits including increased empower-
ment and reductions in child disruptive behavior, but as with
clinician-led programs there was minimal evidence dem-
onstrating enhanced outcomes of team-led family support
programs compared with comparison/control conditions.
Peer-led treatment outcomes were mixed regarding effects
on caregiver empowerment, and there were largely no effects
on child functioning.
Effectiveness of family support
prevention programs
Methods of prevention can be classified along four
levels – universal, selective, indicated, or multilevel.3
Universal prevention programs – sometimes referred to as
primary preventions – aim to reduce the incidence of new
cases of disorder by preventing the onset of disorder. Selec-
tive prevention programs – sometimes termed secondary
preventions – attempt to reduce the prevalence of disorders
via early identification and aggressive treatment of subclinical
problems. Indicated preventions intervene with individuals
displaying symptoms of, but not meeting full diagnostic
criteria for, mental and behavioral health disorders, and these
prevention programs focus on minimizing further negative
consequences. Prevention programs containing more than
one prevention level are classified as multilevel preventions.3
When multilevel preventions are employed, universal inter-
ventions may serve as a screening mechanism, and individu-
als may be identified for more intensive prevention based on
increased risk. Program components were quite similar across
preventions – with nearly all prevention programs includ-
ing instructional and informational elements – therefore,
prevention programs are organized by levels of prevention
(universal, selective, indicated, or multilevel) rather than by
program components.
Universal family support
prevention programs
Universal prevention programs often attempt to promote
mental and behavioral health through education. Universal
preventions are the second most common type of family
support prevention program.3 The universal family support
prevention programs included in this review are described
in Table 4. Positive child outcomes include decreases in
withdrawal, hyperactivity, sexual behavior problems, and
oppositional and delinquent behaviors46–52 – however, there
were some exceptions wherein programs did not have sig-
nificant effects on problem behaviors.53,54 Youth in universal
prevention programs experienced longer delays in the onset
of involvement with antisocial peers, substance use, and
arrests.51 While it is preferable to prevent rather than delay the
incidence or onset, delaying onset is also important because
it reduces the adverse impact of risky behaviors such as sub-
stance use by reducing the duration of them. Improvements
in prosocial behavior such as increases in social competence
were noted in some47,50 but not other55 studies. Reductions in
mental health problems such as anxiety and depression were
also experienced among youth who participated in universal
preventions.26,56–59
Table 3 Team-led programs
Program, source Sample demographics Design Relevant ndings
Vanderbilt Caregiver
Empowerment43
n=250 parents. Youth were primarily
male; ages 6–17 years, and parents
were primarily white
3- and 12-month follow-ups Increased parental knowledge
and mental health services
self-efcacy; no effect on
involvement in treatment. No
effect on child mental health
Multiple Family Group44 n=88. Youth were primarily black,
male; average age 9 years. The Multiple
Family Group program targets youth,
ages 7–11 years
Pre-/post-treatment evaluations Reduced child disruptive
behavior
Support, Empowerment
and Education Group
Intervention45
n=94 parents. Average age of youth
at intake was ∼11 years
RCT. Baseline (intake), 9 months,
18 months (treatment duration was
a minimum of 6 months, and average
time for comparison condition was
12 months)
No differences between the
family support intervention
and treatment as usual for
parent or child outcomes
Abbreviation: RCT, randomized controlled trial.
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Positive parent outcomes included reductions in poor
parenting behaviors – such as parental rejection of the
child, authoritarian parenting strategies, and physical
punishment – as well as increased use of positive parent
management strategies such as greater use of praise and
effective discipline.46,47,49–52,55 However, one study found no
impact of the prevention program on parental monitoring
or consistent discipline.49 Parent–child dyadic interactions
became more positive in response to universal preven-
tions, and these changes were maintained at follow-ups.47,48
Parents in universal preventions also experienced increased
knowledge regarding parenting of children at specific
developmental stages.48 Reductions in parental mental
health problems – including depression and distress47,48 –
and improvements in positive feelings – such as increased
self-esteem and self-efficacy55 were also reported outcomes
of universal programs – with some exceptions.54 Increased
satisfaction with social support and parent satisfaction with
the programs also were reported.47,48,55
Overall, evidence for the effectiveness of universal pre-
ventions is mixed – there were several positive findings, but
also some null effects, as well as evidence that the universal
prevention programs did not yield more beneficial effects
compared with control conditions.53,54 Some evidence
indicated that universal preventions may only be effective26,56
or may be especially effective50,51,58 for reducing mental and
behavioral health problems among children displaying the
highest levels of mental health issues. This interaction effect
suggests that targeting interventions for youth who are at risk
for mental and behavioral health problems may be a more
efficient and productive strategy.60 More targeted preventative
programs – selective preventions – will be reviewed next.
Selective family support
prevention programs
Selective preventions focus on early identification of individ-
uals at high risk for developing a disorder due to experiencing
environmental or psychosocial risk factors for the disorder.
The majority of family support prevention programs are
selective.3 The selective family support prevention programs
included in this review are described in Table 5. Outcomes
for divorcing parents included improved communication,61
reductions in conflict,62,63 and reductions in interjecting
the child in the parent’s conflict,61 but also increases in64
and null effects on conflict.61 Additionally, female – but
not male – ex-spouses perceived improved ability to
Table 4 Universal prevention programs
Program, source Sample demographics Design Relevant ndings
Center for Improvement
of Child Caring Effective
Black Parenting Program
(EBPP)46
n=109 black families. EBPP has
been used with youth up to
age 18 years, but this study
included youth in rst and
second grades
Quasi-experimental. Pre-/post-
treatment, 1-year follow-up
Reduced child hyperactivity and
delinquency, reduced poor parenting
strategies and increased parental use of
praise
FRIENDS56,93 n=594 and 692. Youth were
primarily female; ages 9–16
RCT. Pre-/post-treatment,
12-month follow-up
Reduced anxiety, reduced depressive
symptoms only for FRIENDS participants
with high levels of anxiety at pre-
treatment. Initially, younger participants
experienced stronger effects
Home-based
Intervention57,58
n=80 families. Youth were
primarily female; assessed at
ages 14–15, 20–21
Systematic sampling, assignment
to intervention or control group;
15-year and 20-year post-
treatment follow-ups
Reduced adolescent overall symptoms,
particularly internalizing rather than
externalizing symptoms. Intervention
was more effective among youth from
high-risk relative to low-risk families
Linking the Interests of
Families and Teachers
(LIFT)50,51,66
n=671 and 351. Youth were
in grades ve through 12,
primarily white
RCTs. Pre-/post-treatment,
1- and 3-year follow-ups;
assessments in grades 5–12
Reduced behavioral problems and
increased prosocial behavior. LIFT was
more effective for reducing maternal
aversive behavior among mothers who
demonstrated higher (versus lower) levels
of aversive behavior at pre-treatment
Resourceful Adolescent
Program-Family
(RAP-F)59
n=260. Youth were primarily
Anglo-Saxon, female, from
low to middle socioeconomic
status families; ages 12–15 years
(average age 13)
Pre-/post-treatment, 10-month
follow-up
The family support program (RAP-F) was
not superior to the non-family-support
condition, and both treatment groups
evidenced fewer symptoms of depression
and hopelessness at post-treatment and
follow-up relative to controls
Abbreviation: RCT, randomized controlled trial.
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Table 5 Selective prevention programs
Program, source Sample demographics Design Relevant ndings
Child Anxiety Prevention Study
(Coping and Promoting
Strength; CAPS)94
n=40 families. Youth were primarily
white, male; ages 7–12 (average age 9)
RCT. Pre-/post-treatment, 12-month
follow-up
Reduced the 1-year incidence of new cases of anxiety
disorders and reduced anxiety symptomatology in the
children of parents with anxiety disorders, compared with
control group
Children in the Middle
(CIM)61,62,64
n=76, 345, and 815 parents. CIM
targets youth, ages 3–15, but ages
of children sampled not reported.
Parents were primarily white and of
moderate socioeconomic status
Pre-/post-treatment evaluations,
3- to 9-month follow-ups
Improved parental communication, but effects on parental
conict were inconsistent – including both reductions and
increases in parental conict. Reduced child exposure to
and interjecting into parental conict. No effects on child
behavior in one study, but improvements in child behavior
in another study. High parent satisfaction
Children of Divorce
Intervention Program
(CODIP)71
n=70 parents. Youth were primarily
male; average age ∼10 (range 8–15).
Parents primarily white
RCT. Pre-/post-treatment
evaluations
Reduced child aggression, but no effect on depression,
anxiety, or conduct problems. Improved parent use of
discipline for mothers who had less consistent (as opposed
to more consistent) discipline at pre-treatment
Dads for Life (DFL)63 n=214 fathers. Youth were primarily
female; average age was approximately
11 years
Random assignment to intervention
and control groups. Pre-/post-
treatment, 4-months and 1-year
follow-ups
Reduced conict between divorcing parents. No change
in father’s perceptions of the mother’s and father’s ability
to effectively cooperate as co-parents, but mothers whose
ex-spouses were in DFL perceived improved co-parenting
Family Bereavement Program
(FBP)65,95
n=156 families. Youth were primarily
white, male; average age ∼11
(range: 8–16 years)
RCT. Pre-/post-treatment,
11-month and 6-year follow-ups
Initially, some improvements in youth coping skills, but at
follow-up, only girls and youth with greater difculties at
pre-treatment evidenced reductions in internalizing and
externalizing behaviors. Parents evidenced improvements
in parenting and initial improvements in mental health
Keeping Families Strong (KFS)96 n=10 families. KFS targets youth, ages
9–16, but ages of youth sampled not
reported. Youth were primarily male;
parents primarily white
Pilot study. Pre-/post-treatment
evaluations
Improved child coping and mental and behavioral health
and functioning. Improved parental mental health and
perceptions of familial support and closeness. Increased
mental warmth and acceptance, improved family
functioning, and decreased stressful family events
Metropolitan Area Child Study
Research Group (MACS)75
n=1,500. Youth were primarily black
and male
Random assignment. Pre-/post-
treatment evaluations
The family support level of the intervention – which
was the most comprehensive intervention condition –
decreased aggression only when delivered early (ie, grades
2–3 versus 5–6) and in communities with more resources
and less strain as opposed to communities with fewer
resources and more strain. No levels of the intervention
were effective in preventing aggression among older
elementary school children
New Beginnings Program
(NBP)73,97
n=218 and 240 families. Approximately
50% of youth were female. Youth
were primarily white; average age
∼17–26 years
RCT. Pre-/post-treatment, 6- and
15-year follow-ups
The parent-alone and parent + adolescent NBP conditions
yielded superior effects on youth mental health and
behavioral functioning compared with the control
condition. Youth with higher initial externalizing problems
beneted most from the treatments
(Continued)
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Kuhn and Laird
effectively cooperate as co-parents.63 Other studies yielded
improvements in parenting,65,66 improvements in mental
health (although in one study, improved mental health was
not maintained at follow-up),65–68 prevention of mental
health problems interfering with parenting,69 increased
perceived familial support and closeness and better family
functioning,67 with an exception.70 In one study, an interaction
effect was found such that parental discipline improved for
mothers who demonstrated more inconsistent (as opposed
to less inconsistent, or more consistent) discipline at pre-
treatment71 – adding to the accumulation of findings that
program effects are stronger among high-risk participants.
Another study reported improved parental behaviors with,
and attitudes regarding children, and these gains increased
with time since the intervention.70 Parent satisfaction with
treatments was also reported.62,72
Child outcomes were more mixed – including reductions
in62,68,71 and no effects on64,71 child behavior problems, no
effects on child internalizing problems,68,71 but improved child
coping and mental and behavioral health and functioning.67,73,74
In several studies, reductions in internalizing and externalizing
problems were only experienced among youth at higher risk
for, or experiencing the greatest difficulties with, these prob-
lems pre-treatment.65,71,75
Similar to the evidence for universal preventions, the
evidence for the effectiveness of selective preventions is also
mixed. Selective preventions yielded more beneficial effects
for parents than children, although effects on conflict between
divorcing parents was mixed. For children, both improve-
ments in and null effects on internalizing and externalizing
problems were found. In keeping with the theme of findings
from other programs in this review, selective prevention
effects were sometimes only found among families with the
worst pre-treatment level of functioning – again, suggesting
the increased efficacy of interventions for individuals at
highest risk.
Indicated family support prevention
programs
Indicated preventions target youth displaying minimal but
noticeable symptoms of mental or behavioral health disorders
suggesting the possibility of developing a clinical disorder
in the future, although diagnostic criteria is not met at the
time prevention is enacted.16 The indicated family support
prevention programs included in this review are described in
Table 6 . Child outcomes from the indicated preventions were
generally positive, although outcomes from some programs
were inconsistent. Beneficial child effects included significant
Table 5 (Continued)
Program, source Sample demographics Design Relevant ndings
Parent Management Training –
Oregon (PMTO)69,98
n=102 and 238 families. Youth were
primarily male; ages ranged from
5–21 years
RCT. Pre-/post-treatment, 9-month,
30-month and 9-year follow-ups
In one study, prevented parental depression from adversely
affecting parenting skills, and in another study, reduced
depression among mothers who improved parenting skills.
Reduced child behavior problems. Improved parenting
practices, and reduced involvement with antisocial peers
mediated the reduced rates of adolescent delinquency
Preventive Intervention Project
(Clinician Based Cognitive
Psychoeducational Intervention for
Families)70,72,99
n=7, 93, and 105 families Youth
average ages were 11–12
Random assignments and RCT. Pre-/
post-treatment, 1- and 2-year follow-
ups and every 9–12 months post-
treatment; up to 4.5 years post-
enrollment
Improved positive parental behaviors with and attitudes
regarding children. Increase in treatment gains with
increased time since intervention. Mixed effects regarding
whether the intervention is more effective than control
condition for enhancing children’s understanding of
parental disorders. Not superior to lecture comparison
condition for reducing child internalizing problems.
Moderate to high parent satisfaction
Abbreviation: RCT, randomized controlled trial.
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improvements in youth mental and behavioral health and
social functioning,76–85 with some exceptions of no effects
on mental health or behavioral or social functioning.76,78,86,87
Two studies noted greater benefits of the indicated preven-
tions among youth at higher risk for, or experiencing more,
mental health problems at pre-treatment78,81 – consistent with
the pattern of findings suggesting that treatments targeting
high-risk groups may be more efficient.
Parent outcomes were less studied among indicated pro-
grams compared with universal and selective preventions.3
Among those indicated intervention studies that assessed
parenting outcomes, results were positive – and suggested
improvements in positive parenting and use of effective
discipline strategies.82
The evidence for indicated family support preventions
was generally favorable. Child outcomes included reductions
in both internalizing and externalizing problems, as well as
improvements in the cognitive mechanisms contributing to
depression – in line with the principle of prevention to target
factors implicated in the development and maintenance of
disorders. Two of the three instructional-support-only indi-
cated programs yielded inconsistent findings, while results of
the third instructional-support-only indicated program were
consistently positive. Given that the majority of instructional-
support-only indicated programs produced inconsistent
results relative to programs that combined multiple forms
of support, it is possible that providing only one form of
support – which may not be helpful to all clients – is not as
effective as providing multiple forms of support that are more
likely to impact many. Across all of the indicated programs,
parent outcomes were not well studied, and the only parent
outcomes studied were parenting strategies – parental wellbe-
ing and mental health were not evaluated. Despite the lack of
attention to parenting outcomes among indicated programs,
Table 6 Indicated preventions programs
Program, source Sample demographics Design Relevant ndings
Cognitive Behavioral
Interventions for Trauma in
Schools (CBITS)79–81
n=48, 126, and 198. Youth
average age ∼11 years
Pre-/post-treatment,
3-month follow-up
Reduced PTSD symptoms, depression,
and psychosocial dysfunction compared
with wait-list control. Greater decrease
in PTSD and depression symptoms
among intervention group youth with
clinically signicant levels of PTSD
or depression at pre-treatment. No
difference between treatment and
control groups in acting out behavior,
shyness, or learning difculties
Coping Power Program
(CPP)82–84
n=183–245. Youth were
primarily black or white, male,
fourth and fth graders
Pre-/mid-/post-treatment,
1- and 3-year follow-ups
Improved youth behavior and parenting,
especially for more comprehensive CPP
interventions
Early Risers “Skills for
Success”85
n=125. Early Risers targets
youth, ages 6–12 years, but this
study included fourth-graders
with average age ∼6 years.
Youth were primarily male
RCT. 4-year follow-up Higher levels of prosocial functioning
compared with controls
Penn Resiliency Program
(PRP)76–78
n=293–693. Youth were ages
11–13 years, primarily male,
white or Australian
RCTs. 18-month to 3-year
follow-ups
Mixed effects, and weak support. Often
no effect on depression, anxiety, or
social skills. In one study, improvements
in explanatory style (associated with
depression) at 2-year follow-up. More
effective for preventing internalizing
and adjustment disorders among girls
and individuals with elevated initial
symptoms
Queensland Early Intervention
and Prevention Anxiety
Project (QEIPAP)86,87
n=128. Youth were ages 7–14;
primarily white
RCT. 6-, 12-, and
24-month follow-ups
Inconsistent effects on reducing
incidence and prevalence of anxiety
disorders over time – eg, QEIPAP not
superior to control post-treatment, but
treatment gains emerged at 6-month
and 2-year follow-ups
Abbreviations: PTSD, posttraumatic stress disorder; RCT, randomized controlled trial.
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parental outcomes that were addressed showed beneficial
effects of the indicated programs.
Multilevel family support prevention
programs
Multilevel family support prevention programs integrate
assessment and prevention to maximize beneficial out-
comes. With multilevel family support preventions, the
intensity and nature of the prevention strategies provided
may be adjusted depending on an individual’s respon-
siveness. Multilevel family support preventions are as
common as indicated preventions and – like indicated
preventions – were relatively rare compared with universal
and selective programs.3 The multilevel family support
prevention programs included in this review are described
in Table 7. Beneficial child outcomes associated with mul-
tilevel family support preventions included reductions in
externalizing behavior88,89 and internalizing problems,90 as
well as improved prosocial behavior.88 Participation in more
intensive prevention levels accounted for two programs’
beneficial effects,90,91 and one study reported an interaction
effect wherein intervention participants at highest initial
risk evidenced reductions in diagnoses and behavioral
symptoms.92
Similar to indicated preventions, parent outcomes were
not a primary focus of studies testing multilevel family sup-
port preventions. However, parenting outcomes reported
were positive, and included improvements in mental health
and parenting skills.88 Additionally, an interaction effect was
found wherein parents in a more intensive prevention level
experienced reductions in the use of over-reactive parent-
ing strategies91 – again suggesting that greater intensity of
intervention may be helpful.
Multilevel prevention programs appeared to be highly
effective. Positive child outcomes primarily included
reductions in externalizing behavior and involvement with
antisocial peers. The reduction in involvement with antiso-
cial peers is in line with the aim of prevention programs to
alter causal mechanisms contributing to disorder. Although
parent outcomes received less attention, positive caregiver
outcomes included both mental health improvements as well
as improvements in parenting behavior and skills.
Prevention effectiveness summary
Overall, prevention programs appear to be effective –
although effectiveness varies both across levels of preven-
tion, and within levels across specific prevention programs.
Multilevel programs and indicated preventions yielded
Table 7 Multilevel preventions programs
Program, source Sample demographics Design Relevant ndings
Adolescent Transition
Program (ATP)90
n=106. Youth were primarily black
and female; assessed in 6th–9th
grades
RCT. Three-yearly
assessments
ATP prevented escalations in
depressive symptoms. Intervention
effect was driven by participation in the
selected and indicated levels of ATP
Fast Track92 n=891. Youth were primarily black;
average age ∼6 years. Ten-year
intervention (through grade 9)
RCT. Assessments after
grades 3, 6, and 9
Intervention participants at highest
initial risk evidenced reductions in
diagnoses and behavioral symptoms
Incredible Years88 n=18 families. Youth were primarily
black, female; ages 5–12 (average
age 8)
Pilot study. Pre-/post-
treatment
Reduced youth behavioral problems,
improved prosocial behaviors,
improved parental depression and
parenting skills (laxness, over-reactivity
and verbosity)
Teen Triple P – Positive
Parenting Program91
n=280. Youth were primarily male;
ages 8–13 (average age 10 years),
from families with income below
the poverty line
No control group. Pre-/
post-treatment evaluations
Fewer adolescent behavior problems
and less use of over-reactive parenting
strategies in more intensive Teen
Triple P level compared with the less
intensive level and waitlist control
conditions
Raising Healthy Children89 n=959. Youth were primarily white
and male. Study began when youth
were average age ∼7 years, in
1st and 2nd grades. Intervention
implemented through high school;
outcomes assessed during 6th–10th
grades (early to mid-adolescence)
Matched random assignment Reduced growth in frequency of
alcohol and marijuana use, but no
effect on use versus non-use
Abbreviation: RCT, randomized controlled trial.
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more consistently positive results than the less intensive
preventative interventions – selective and universal. Findings
from studies that evaluated whether increased intensity of
preventions improved outcomes are in line with a body of
other evidence suggesting that increasingly intensive and
comprehensive levels of prevention are more effective
than less intense preventative measures. Another consistent
finding across prevention levels was that individuals with
elevated levels of mental and behavioral health problems
experienced better outcomes compared with individuals
less in need of the services. This suggests that it may be
more efficient for prevention efforts to target individuals at
high-risk for mental and behavioral health problems than
to target the entire population – as in universal prevention
strategies. It is possible that more consistently positive evi-
dence was found among indicated and multilevel preventions
simply because there were fewer of these programs than
the universal and selective preventions. Overall – across
all prevention levels – parent outcomes were less studied
than child outcomes. Parent outcomes primarily included
improvement in parenting strategies, but some studies also
focused on parental mental health and wellbeing. In terms
of child outcomes, reductions in externalizing behavior were
most common, followed by improvements in mental health
and internalizing problems such as anxiety and depression,
and only a few studies noted improvements in prosocial
behavior such as social competence.
Overall summary
Family support programs demonstrated some effective-
ness in improving caregiver mental health and parenting
strategies as well as enhancing child mental and behavioral
health. Among treatment programs, clinician-led programs
that provided a combination of instructional, informational,
and advocacy support demonstrated the most effectiveness.
Peer-led programs had the weakest research base and least
effectiveness. More research is needed to investigate the
efficacy of peer-led programs given that parents/veteran
parents who typically lead peer-led programs can serve as
important supports and mentors for parents enrolled in the
family support programs.2 Among prevention programs, mul-
tilevel and indicated programs demonstrated greater levels
of effectiveness compared with the lower-level – universal
and selective – preventions. Across all programs reviewed,
those that included the most diverse forms of support were
the most effective. Combining different forms of support
may be useful, because different clients may need different
forms of support and approaches. The evidence reviewed here
suggests that when family support programs are riveted to
providing one form of support, their effectiveness is limited.
In other words, being rigid in the provision of support can
shut out potential solutions to meeting each family’s needs.
For instance, multilevel prevention programs can improve the
ability to select the best forms of support and tailor them for
individual clients and presenting concerns. While all family
support programs need not provide every form of support,
it may be beneficial for family support programs to be open
to using forms of support other than the primary form to
enhance effectiveness and efficiency.
Disclosure
The authors report no conflicts of interest in this work.
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