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Question
Question: Does an intervention comprising social skills training for disruptive boys at school, and training for parents during family visits, reduce substance use behaviours during adolescence?
People: One hundred and seventy-two boys with scores above the 70th percentile on the teacher-rated disruptiveness scale of the Pre-School Behaviour Questionnaire at age 6 years.
Setting: Schools in low socioeconomic neighbourhoods of Montreal, Quebec.
Intervention: Preventative intervention versus control. Boys allocated to the intervention group (n=46) participated in a school-based, small group, social and problem-solving skills training intervention from ages 7 to 9 years. A second component was delivered to parents, who were taught to recognise problematic or inappropriate behaviours, set objectives and reinforce appropriate behaviours based on the Oregon Social Learning Care Model. Boys in the control group (n=126), either received no intervention or intensive observation.
Outcomes: Alcohol use, combining measures of frequency and drunkenness (maximum score of 8), and number of different substances used (maximum score of nine) over the previous 12 months, measured annually from ages 14 to 17 years using the Self-Reported Antisociality Questionnaire.
Patient follow-up: Seventy six per cent at 17 years of age.
Methods
Design: Randomised controlled trial.
Allocation: Concealed.
Blinding: Single blind (researchers).
Follow-up period: Eight years postintervention (until 17 years of age).
Main results
The alcohol use frequency score was significantly lower in the intervention group than the control group at ages 14 and 15, but not at 16 and 17. Drug use score was significantly lower in the intervention group at ages 16 and 17, but not at ages 14 and 15 (see online table 1 for outcome data). There was an overall tendency for frequency of alcohol use and number of drugs used to increase from 14 to 17 years. Conditional multivariate growth models showed that the intervention was associated with a lower frequency of alcohol use at 14 years of age, but was not significantly associated with a frequency of alcohol use from 14 to 17 years. Conversely, the intervention was not associated with lower number of drugs used at 14 years, but was significantly associated with a reduced number of drugs used from 14 to 17 years of age.
Conclusions
An intensive 2-year social skills training intervention delivered to disruptive boys aged 7–9 years from low socioeconomic backgrounds, combined with parental training, can reduce substance use behaviours in adolescence.
Abstracted from
Commentary
Castellanos-Ryan and colleagues examined the long-term effects of a 2-year preventive intervention designed to reduce conduct problems among at-risk boys. The intervention included direct interventions with the boys and interventions with parents and teachers. Initial benefits (reduced impulsivity and healthy peer relationships) translated to reduced alcohol and drug use from ages 14 to 17, 10 years after the intervention began.
This high-quality study raises several important questions for future research. One concerns prevention efficacy and pathways to substance use among girls, who were not included in this study. Solutions for how to effectively screen young girls who may be at risk for future substance use problems, and how to reduce their risk, remain largely unknown. Assessment of deviance relative to same gender samples may aid in identification. Gender specific approaches may (or may not) be necessary.
Another issue raised is the impact of the substantial variability in quantity of services received by the boys and their parents. The number of parenting sessions ranged from 0 to 46, with a mean of 17 and only 50% of teachers adopted the classroom intervention. Complier average causal effect modelling might be meaningfully applied to these data to help identify how efficacy varies with intervention exposure across intervention type. The results also highlight the importance of risk factors for future substance use at ages 11–13 years, suggesting the need for continued or renewed intervention in that period.
The results are consistent with the conceptualisation of substance use as part of a broader spectrum of externalising problems, supporting a focus on early conduct problems as an important prevention strategy. They also highlight how developmental context (eg, early onset conduct problems) should be taken into consideration in research on adolescent substance use, prevention, and treatment. Finally, the results show the potential long-lasting benefits of early intervention, but also the need to conceptualise the early-onset conduct problems as a chronic condition in need of developmentally targeted interventions across multiple developmental periods.
Footnotes
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Sources of funding Ministère de l’Éducation, du Loisir et du Sport du Québec, Fonds de la Recherche en Santé de Québec, the Canadian Institutes of Health Research, the Social Science and Humanities Research Council of Canada, the National Health Research and Development Program, the Fonds Québécois de Recherche sur la Société et la Culture, and the Fonds Québécois de Recherche en Santé.
Footnotes
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Competing interests None.