Familias Unidas

Study 1

Summary

Pantin et al. (2003) used a mixed-model design with random assignment to either the treatment or a no-treatment control group. A total of 167 Hispanic families of sixth and seventh-grade students from three South Florida public schools were stratified by grade within each school and randomly assigned to intervention and no-intervention control conditions.

Pantin et al. (2003) found that the intervention group, relative to the control group, showed significant increases in 

• School bonding/academic achievement
• Parental investment.

Evaluation Methodology

Design: A randomized, mixed-model design was utilized with an intervention condition (Familias Unidas or a no-treatment control condition) as the between groups factor and time as the within groups factor. A total of 167 participants/families were successfully recruited from three middle schools in low-income areas of Miami, Florida. Inclusion criteria included: (a) Hispanic 6th and 7th grade students with no history of psychiatric hospitalization; (b) residing with at least one Hispanic immigrant parent willing to participate in the intervention; and (c) the family had no plans to relocate out of the catchment area. Letters were sent home to parents of all students in the three participating schools inviting them to learn more about the program. Of the 475 students whose parents returned the letters, 1.2% indicated that their adolescents were transferring to another school outside the catchment area, 69.4% indicated interest in participating and 29.2% responded that they were not interested. Of the 330 families who indicated interest in participating, 49% were not included in the baseline assessments or the randomization procedure. The primary reasons for non-inclusion were parents' schedule conflicts (15%), unresponsiveness to letters and phone calls from project staff (10%), parents deciding not to enroll in the program (8%), moving out of the catchment area (6%), invalid phone numbers or addresses (5%), and current treatment for family crisis or psychological disorders (5%). A total of 167 participants/families met the inclusion criteria and completed baseline assessments (administered immediately prior to the intervention). Upon completing the baseline assessment, the families were randomly assigned to either the Familias Unidas intervention (n = 96) or to the no-treatment control condition (n = 71) in a 60/40 ratio (60% of the sample was assigned to the experimental condition to provide power for subsequent analyses of the intervention process).

Parents in the Familias Unidas group attended a mean of 24 group sessions. Recruitment and baseline assessments occurred in the fall and winter of 6th or 7th grade. Assessment 2 occurred in the spring (3 months post baseline), Assessment 3 in the summer (6 months post baseline), Assessment 4 in the fall of the following school year (9 months post baseline), and Assessment 5 in the winter of the following school year (3 months post program completion). Participants were engaged into the study and administered baseline assessments on a rolling basis during the fall and winter of 6th or 7th grade, and the timing of subsequent assessments was arranged according to the date of each participant's baseline assessment.

Sample: The adolescents in the Familias Unidas group were 59% male, while the adolescents in the control group were 63% male. The mean age of participating adolescents was 12.4 years with a range from 10.69 to 14.89 years. The largest percentage of participants were Cuban (39%), followed by Central and South Americans (29 and 17%, respectively), and a small proportion of Puerto Ricans/Dominicans (5%). The remaining 10% identified themselves as "Other" Hispanic. The majority of parents (94%) and half of the adolescents (49%) were born outside of the United States. The range of years living in the United States for parents was from less than 1 year to 42 years, with a median of 11 years. More than a quarter (26.3%) of the adolescents had been residing in the United States for less than 5 years, and the average length of residence for adolescents was 8.5 years. Fifty-seven percent of the families reported speaking only Spanish at home while 36% of families reported speaking Spanish and some English at home. The median annual household income was between $15,000 and $20,000, and the modal level of parent education was 12th grade (35%), with a substantial percentage obtaining only elementary or some high school education (28%) and the remaining 37% receiving some post-secondary school education including college or graduate school.

Measures: Three outcome composites were measured in this study: parental investment, adolescent behavior problems, and adolescent school bonding/academic achievement. Each composite was derived by summing adolescent and parent reported scales. Each scale was standardized, using the baseline mean and standard deviation, prior to summation.

Parental Investment: The parental investment composite was measured as the equally weighted sum of five scales: (a) the parent and adolescent reported Extent of Involvement and Positive Parenting subscales from the Parenting Practices Scale, a 25-item measure assessing various dimensions of parenting; and (b) the adolescent-reported Family Support subscale from the Social Support Appraisal Scale, a 31-item measure assessing perceived support from family, peers, and teachers.

Adolescent Behavior Problems: The behavior problems composite included intrapersonal and interpersonal aspects of functioning and was measured as the equally weighted sum of eight parent and adolescent reported scales. The adolescent reports assessed both internal states and observable behaviors. Parent reports were obtained only from a behavioral perspective, because parent reports of teens' internal states require excessive inference on the part of the parent. Parent reports were obtained using the Conduct Disorder, Socialized Aggression, Attention Problems, and Motor Excess subscales from the Revised Behavior Problem Checklist, an 89-item measure of child behavior problems. Adolescent reports were obtained from (a) the Anger Control and Hyperactivity subscales of the Conners-Wells Self-Report Scale, a 27-item measure of self-control and restlessness; (b) the Aggression subscale from the Interpersonal Competence Inventory, a 21-item measure assessing aggression, popularity, and academic competence; and (c) the Behavior Scale Part I, a 13-item index assessing the frequency of deviant and antisocial behaviors.

School Bonding/Academic Achievement: The adolescent school bonding/academic composite was measured as the equally weighted sum of 10 scales: (a) the parent and adolescent reported School Bonding, School Achievement, and Disinterest in School subscales from the School Attitudes/Bonding Scale, a 35-item instrument that assesses adolescents' connections to school, teachers, and learning; (b) the parent and adolescent reported Academic Achievement subscales from the Adolescent Competence Scale, an 18-item scale that assesses adolescent and parent reports of the adolescent's competence in academic achievement, peer relationships, involvement in activities, and classroom behavior; (c) the adolescent-reported Academic Competence Scale; and (d) the Intellectual/School Self-Concept subscale from the Piers-Harris Children's Self-Concept Scale, and an 80-item measure that assesses adolescent self-concept in six domains (behavior, academics, popularity, happiness, physical appearance, and anxiety).

Analysis: Mixed-model analyses of variance were used, focusing on the condition by time interaction. All analyses were conducted on an intent-to-treat basis, and all participants were included in the analyses regardless of the number of sessions or assessments they completed. Student's t -tests were used to determine the presence or absence of baseline differences in each outcome variable. In cases where baseline differences by condition emerged, baseline scores were covaried in subsequent analyses, and subsequent analyses were restricted to the remaining assessment points. An Expectation Maximization (EM) algorithm was used to impute any missing responses for each variable at each assessment time, provided that the adolescent and/or parent provided some valid data at that assessment point. To evaluate the criteria for mediation, the mixed-model ANOVA for adolescent behavior problems was re-run with a change in parental investment entered as an additional covariate.

Outcomes

Fidelity: In order to ensure fidelity in implementation, two mechanisms were established: (1) each group session was videotaped and reviewed by the senior author in order to provide ongoing corrective feedback to facilitators in weekly supervision meetings, and (2) 25% of all group sessions were randomly selected for videotape rating by independent adherence raters.

Baseline Equivalence and Attrition: Analyses of between group differences at baseline indicated that the Familias Unidas group had significantly lower mean levels of adolescent problem behavior compared to the control group. No other between-group differences were statistically significant at baseline. Retention was high, with 95% of participants completing assessments at three or more time points and 98% of the original baseline sample completing the final 12-month assessment. Families in the control condition were no more likely to miss an assessment point than were those in the experimental condition.

Posttest:

Parental Investment: Mixed model analyses of variance revealed a significant Time x Condition interaction on parental investment. The control condition trajectory was more positive than was the experimental condition trajectory between baseline and 3 months, but the control condition trajectory flattened out and began to decrease sharply at 9 months. The experimental condition demonstrated its greatest increase between 3 and 6 months. Although it too began to decrease between 9 and 12 months, this decrease was milder than what was in the control condition.

Adolescent Behavior Problems: A mixed model analysis of covariance (with baseline scores covaried) revealed a significant Time x Condition interaction on adolescent behavior problems. The experimental condition demonstrated a steady decline in behavior problems across all data collection points, whereas the control condition demonstrated a sharp increase between 3 and 6 months before decreasing sharply from 6 to 9 and from 9 to 12 months. At 12 months, the treatment and control conditions looked similar.

School Bonding/Academic Achievement: There was no significant Time x Condition interaction on School Bonding/Academic Achievement.

Attendance Effects: In order to determine whether intervention dosage was a significant predictor of change in the outcome variables within the experimental condition, the number of group sessions that each family attended was interacted with time in growth curve models for the two outcome composites that differed significantly by condition. Linear and quadratic models were estimated for both outcome composites. A significant linear Time x Attendance interaction emerged for Parental Investment. There was also a significant quadratic trend, but no quadratic Time x Attendance interaction. Parents with lower baseline levels of investment tended to attend more intervention sessions and to display greater increases in investment during the intervention. No linear or quadratic Time x Attendance interactions emerged for Adolescent Behavior Problems.

Mediating Role of Change in Parental Investment on Change in Adolescent Problem Behaviors: A Time x Condition mixed-model analysis of covariance was conducted on the adolescent behavior problems composite, with change in parental investment included as an additional covariate (along with baseline adolescent behavior problems). For each step in the analysis, changes in parental investment between consecutive assessment intervals were used to predict adolescent behavior problems scores at the end of that interval (e.g., 3 months), and was repeated for the remaining time intervals. Results indicated that change in parental investment predicted changes in adolescent behavior problems in both the experimental and control conditions. This suggests that parental investment may exert a strong influence on adolescent problem behaviors regardless of experimental manipulation.

Long-term: No long-term data was collected or analyzed.

Study 2

This study evaluated the efficacy of Familias Unidas combined with Parent-Preadolescent Training for HIV Prevention (PATH), a Hispanic-specific, parent-centered intervention, in preventing adolescent substance use and unsafe sexual behavior. Unfortunately, since Familias Unidas was not evaluated for effects on its own (separate from any effects produced by PATH), it cannot be determined to what degree (if any) Familias Unidas effected changes in adolescent behavior. As such, this evaluation cannot be considered a replication of the Familias Unidas program.

Summary

Prado et al. (2007) evaluated the efficacy of Familias Unidas combined with Parent-Preadolescent Training for HIV Prevention (PATH), a Hispanic-specific, parent-centered intervention, in preventing adolescent substance use and unsafe sexual behavior. Adolescents and their families from three Florida middle schools were randomly assigned to one of three conditions: Familias Unidas Plus PATH, English for Speakers of Other Languages plus PATH, or English for Speakers of Other Languages plus HeartPower! for Hispanics.

Prado et al. (2007) found that the intervention group, relative to the control group, showed significantly lower

• Inconsistent condom use during vaginal (39%) and anal (60%) intercourse
• Days of having unprotected sex while under the influence of drugs or alcohol
• Numbers of sexual partners.

Evaluation Methodology

Design: This study used a 3 (condition) x 5 (time) randomized controlled design. Participants were randomized using an urn randomization computer program that balanced on the following adolescent characteristics: gender; years in the United States (0 - 3, 3 - 10, or more than 10); having initiated substance use (yes, no); and having initiated (yes, no) oral, vaginal, or anal sex.

Adolescents and their families were recruited for participation from three middle schools in the Miami-Dade county school system in two cohorts: May 2001 through July 2004 and May 2002 through July 2005. Recruitment took place during April through June of the adolescents' seventh-grade year. During recruitment, study staff visited all seventh grade homerooms in the participating schools on several occasions to distribute recruitment fliers to students. The flier briefly described the study and the potential benefits of participation. Adolescents were asked to return an enclosed letter signed by their parents indicating whether the parents were interested in learning more about the study. Parents who indicated interest were contacted by project staff. Parents who were still interested after speaking with project staff were screened (along with their adolescents) for eligibility. Families were considered eligible for participation provided that (a) at least one parent was born in a Spanish-speaking country in the Americas, (b) the adolescent was attending one of the three participating middle schools, (c) the adolescent would advance to the eighth grade in the next school year, (d) neither the adolescent nor the primary parent had ever been hospitalized for psychiatric reasons, (e) the family was not planning to move out of the Miami area during the first year of participating or out of the South Florida area during the three years of the study, (f) the adolescent was living with an adult primary caregiver who was willing to participate in the study, and (g) a primary caregiver was available on weekday evenings to attend weekly meetings. The mobility rate for the participating schools was 40%, and approximately 26% of potential participants were ineligible to participate because they were planning to move out of the catchment area. One parent from each family participated in the study with the adolescent.

Of the 649 potential families, 70 refused to participate. Of the remaining 579, 266 met inclusion criteria and were randomized into one of three interventions, each with two modules: the Familias Unidas plus PATH (n = 91), English for Speakers of Other Languages (ESOL) plus PATH (n = 84), or ESOL plus HeartPower! for Hispanics (HEART) (n = 91). A no-treatment control group was not used in this evaluation. Instead, the authors state that the Familias Unidas plus PATH group served as the treatment group and the remaining two groups (ESOL plus PATH and ESOL plus HEART) served as attention control groups. In both control conditions, ESOL was used as an attention control for Familias Unidas. In the second control condition, HEART was used as an attention control for PATH. The term attention control is used to refer to a module intended to provide equivalent amounts of dosage and participant-facilitator contact. In each of the three conditions, families participated in the first module between September and December and in the second module between January and April. All intervention conditions were parent-centered, with adolescents' participation in intervention activities limited to a small number of family visits and parent-adolescent discussion circles in the Familias Unidas and PATH modules. In these family visits, facilitators met separately with each parent and adolescent dyad and conducted exercises to help the parent enact the skill learned in the group sessions with the adolescent. Adolescents also participated in parent-adolescent discussion circles. In these parent-adolescent discussion circles, facilitators met jointly with all of the parent and adolescent dyads in multifamily group sessions.

All three conditions were designed to deliver an equivalent dosage of 49 hours, although the number and type of sessions varied. In the Familias Unidas plus PATH condition, there were 15 group sessions, 8 family visits, and 2 parent-adolescent circles. In the ESOL plus PATH condition, there were 8 ESOL classes, 6 group sessions, and 2 family visits. In the ESOL plus HEART condition, there were 8 ESOL classes and 7 group sessions.

PATH is a theoretically based HIV prevention curriculum designed to promote responsible sexual behavior by training parents to become effective HIV educators for their children. PATH is designed to increase parents' and adolescents' knowledge about HIV and to promote parent-adolescent communication about HIV risks. PATH was originally designed for a multicultural sample that included Hispanics and was later adapted specifically for use with a Hispanic sample.

HEART is designed to reduce adolescents' risk for cardiovascular disease and to promote adolescent cardiovascular health by (a) increasing awareness of cardiovascular risk factors such as cigarette use, and (b) improving attitudes toward exercise and nutrition. HEART encourages parents to be involved in their adolescents' cardiovascular health, but it is not specifically designed to reduce risk for adolescent illicit drug use or unsafe sexual behavior.

The ESOL classes aimed to help parents communicate more effectively in English. It was expected that parents would be interested in this module because the majority of them were monolingual and had no working knowledge of English.

Of the 313 participants deemed ineligible for participation, 44 adolescents were not promoted to the 8th grade, 26 were not living within the catchment area of the three participating middle schools, 163 primary caregivers were not available to meet at least once per week, and 80 families were planning to move outside of the catchment area of one of the three participating middle schools.

Participants were assessed at baseline, randomized into experimental conditions, and reassessed at 6, 12 (post-intervention), 24, and 36 months post-baseline. In the Familias Unidas plus PATH group, 80 participants completed the 6-month post-baseline assessment, 79 completed the 12-month post-baseline assessment, 76 completed the 24-month post-baseline assessment, and 71 completed the 36-month post-baseline assessment. In the ESOL plus PATH group, 78 participants completed the 6-month post-baseline assessment, 75 completed the 12-month post-baseline assessment, 71 completed the 24-month post-baseline assessment, and 70 completed the 36-month post-baseline assessment. In the ESOL plus HEART group, 84 participants completed the 6-month post-baseline assessment, 74 completed the 12-month post-baseline assessment, 70 completed the 24-month post-baseline assessment, and 70 completed the 36-month post baseline assessment. The active intervention phase constituted most of the first year of participation. Adolescent measures were completed on laptop computers with the audio computer-assisted self-interview system. The content of each questionnaire, along with the response choices, was read to the adolescent through a set of headphones connected to a laptop computer. The adolescent indicated his or her response using the keyboard or mouse. Parent assessments were completed in interview form with a trained Hispanic interviewer. To minimize potential interviewer bias, interviewers were blind to condition.

Sample: The adolescents in the study were 48% male with a mean age of 13.4 years, and their primary caregivers were 87% female with a mean age of 40.9 years. Only 18.6% of the families reported a household income greater than $30,000 per year. Forty percent of the adolescents were born in the United States. Immigrant adolescents (n = 159) and their parents were born in Cuba (40%), Nicaragua (25%), Honduras (9%), Colombia (4%), and other Hispanic countries (22%). Of the foreign-born adolescents, exactly half had been living in the United States for less than 3 years, whereas the other half had been living in the United States either between 3 and 10 years (n = 54; 34%) or more than 10 years (n = 25; 16%). Parents of U.S.-born adolescents were born primarily in Nicaragua (33%), Cuba (20%), and Honduras (12%).

Measures: The measures reported in this article were part of a larger assessment battery, which ranged from 60 to 90 minutes for adolescents and 45 to 60 minutes for parents. Parents and adolescents completed the battery in the language of their choice. Adolescents and parents completed a demographics form, which obtained their date and country of birth, number of years lived in the United States, and national origin. Parents were also asked about their marital status and household income.

Acculturation was measured by the Bicultural Involvement Questionnaire-Revised. This measure assesses Americanism and Hispanicism in terms of both (a) comfort and enjoyment with American and Hispanic cultural practices, and (b) how much participants would want or like to utilize American and Hispanic cultural practices. Two questions were omitted from the Americanism and Hispanicism items: language used at work for adolescents, and language used at school for parents. Each item on both the Americanism and the Hispanicism subscales was rated on a 5-point Likert-type scale, with higher scores on each subscale representing more of an orientation to the respective culture.

Parent reports of family functioning were assessed with four indicators: parental involvement, positive parenting, family support, and parent-adolescent communication. Parental involvement (12 items) and positive parenting (6 items) were assessed via the corresponding subscales from the Parenting Practices Scale. Family support (6 items) was assessed via the corresponding subscale from the Family Relations Scale. Parent-adolescent communication (20 items) was assessed with the Parent-Adolescent Communication Scale. At each time point, a Family Functioning factor score was computed by taking the participant's standardized score on each of the family functioning indicators, multiplying this standardized score by the corresponding factor loading for the indicator, and summing these four weighted indicators.

Substance use was measured with items similar to those used in the Monitoring the Future Study. At each assessment, adolescents were asked whether they had ever smoked, drunk alcohol, or used an illicit drug in their lifetime and in the past 90 days. Adolescents who responded "yes" to having used an illicit drug in the past 90 days were asked about the frequency of their use of a variety of drugs, including marijuana, cocaine, amphetamines, methamphetamines, and barbiturates.

Sexual risk behaviors were measured with items from the Sexual Behavior instrument. At each assessment time point, adolescents were asked to indicate whether they had ever had sex in their lifetime and in the past 90 days. Adolescents who reported having had sex in the past 90 days were asked whether they had engaged in unprotected sex during that time. Adolescents who reported ever having sex were also asked whether they had engaged in unprotected sex at last intercourse, had consumed alcohol or drugs before their last sexual intercourse, and had ever contracted a sexually transmitted disease.

Analysis: Growth curve analyses were used to estimate individual trajectories of change and to test for slope differences among the three study conditions over time. In these analyses, Familias Unidas plus PATH served as the reference group so that each control condition was compared with Familias Unidas plus PATH. Therefore, the coefficients obtained for the ESOL plus HEART and ESOL plus PATH conditions indicate the direction and degree to which each condition differs from the Familias Unidas plus PATH condition. For each of the four distal outcomes (past 90-day alcohol use, past 90-day cigarette use, past 90-day illicit drug use, and past 90-day unprotected sex), data from all five assessment points were used. Because the substance use outcomes were binary, the categorical option in Mplus was used. For family functioning, which was a proximal outcome and was expected to change primarily during the active intervention period, analyses focused on changes between baseline and 12-months post-baseline. Mediational analyses were planned to examine whether significant changes in family functioning (if any) might have mediated the effect of the intervention on any of the four distal outcomes. For each outcome for which the effect of condition was statistically significant, a growth curve controlling for the slope of family functioning was then estimated. For each outcome, mediation was assumed if the path from intervention condition to the slope of the outcome variable was reduced to nonsignificance when the slope of family functioning was added to the model.

The study used an intent-to-treat analysis, such that participants continued to be assessed at each time point, whether or not they had dropped out of the intervention.

Outcomes

Fidelity: All intervention sessions were videotaped with participants' consent. To assess adherence to the modules, independent raters, blind to condition, rated all of the videotaped group sessions and parent-adolescent discussion circles in each condition as well as 25% of the individualized family visits. There were no significant differences in adherence ratings by intervention module.

Baseline Equivalence: Chi-square tests and analyses of variance indicated no significant differences by intervention on any of the demographic characteristics; acculturation; family functioning; or alcohol use, cigarette use, illicit drug use, or unprotected sex in the past 90 days.

Posttest:

Alcohol Use: Growth curve analyses showed no significant differences in past 90-day alcohol use between Familias Unidas plus PATH and either of the other two conditions.

Cigarette Use: Growth curve analyses indicated significant differences in past 90-day cigarette use between Familias Unidas plus PATH and ESOL plus PATH and between Familias Unidas plus PATH and ESOL plus HEART. The mean trajectory of smoking in Familias Unidas plus PATH decreased, while the mean trajectories of smoking increased for the remaining two groups.

Illicit Drug Use: Growth curve analyses indicated significant differences in past 90-day illicit drug use between Familias Unidas plus PATH and ESOL plus HEART, but no significant differences were observed between Familias Unidas plus PATH and ESOL plus PATH. The observed mean frequency of illicit drug use decreased in Familias Unidas plus PATH but increased in ESOL plus HEART between 24 and 36 months post-baseline.

Unprotected Sexual Behavior: Due to the small number of participants engaging in sexual behavior in the past 90-days, growth curve analyses were not estimated for past 90-day unprotected sex. Fisher's exact tests conducted at each time point indicated that there were no significant differences by condition for unprotected sexual behavior.

Family Functioning: Growth curve analyses indicated significant differences in family functioning between Familias Unidas plus PATH and ESOL plus PATH and between Familias Unidas plus PATH and ESOL plus HEART. The mean trajectory of family functioning in Familias Unidas plus PATH increased, while the mean trajectories of family functioning decreased in both ESOL plus PATH and ESOL plus HEART.

Mediational Analyses: Mediational analyses were conducted to determine whether family functioning mediated the effects of intervention on past 90-day smoking and illicit drug use. Mediational analyses were not conducted on past 90-day alcohol use or past 90-day unprotected sexual intercourse because there were no significant intervention effects on these outcomes. When the slope of family functioning on the growth curve of smoking was controlled, the results indicated that neither of the growth curve trajectories between Familias Unidas plus PATH and ESOL plus PATH nor those between Familias Unidas plus PATH and ESOL plus HEART differed significantly. Thus, changes in family functioning partially mediated the effect of the intervention condition on smoking. Similarly, when the slope of family functioning was controlled, results indicated that differences in the growth trajectories for illicit drug use between Familias Unidas plus PATH and ESOL plus HEART were no longer significantly different; thus changes in family functioning partially mediated the effect of intervention on illicit drug use.

Post-Hoc Analyses

Family Functioning: The family functioning factor was decomposed into its four component indicators (parent involvement, family support, positive parenting, and parent-adolescent communication) in order to explore the specific aspects of family functioning on which Familias Unidas plus PATH differed significantly from the other conditions. Growth curve analyses indicated significant differences in positive parenting between Familias Unidas plus PATH and ESOL plus HEART and between Familias Unidas plus PATH and ESOL plus PATH. The mean trajectory of positive parenting in Familias Unidas plus PATH increased while the mean trajectories of positive parenting decreased with ESOL plus PATH and ESOL plus HEART. Significant differences also emerged for parent-adolescent communication, where the mean trajectory for Familias Unidas plus PATH increased and the mean trajectory of parent-adolescent communication decreased in ESOL plus PATH. No significant differences were observed in the growth trajectories for parent-adolescent communication between Familias Unidas plus PATH and ESOL plus HEART. No significant differences by condition emerged for parental involvement or family support.

Positive Parenting and Parent-Adolescent Communication: Post-hoc analyses were performed in order to determine whether positive parenting and parent-adolescent communication mediated the effects of the intervention on past 90-day smoking and illicit drug use. When controlling for the slope of positive parenting on the growth curve of smoking, differences in the growth trajectories between Familias Unidas plus PATH and ESOL plus PATH and between Familias Unidas plus PATH and ESOL plus HEART were reduced to non-significance. Similarly, when controlling for the slope of parent-adolescent communication, the differences in the growth trajectories for smoking between Familias Unidas plus PATH and ESOL plus PATH were reduced to non-significance. This suggests that changes in positive parenting and changes in parent-adolescent communication each partially mediated the intervention effect on smoking. When the slope of positive parenting was controlled for, differences in the growth trajectories for illicit drug use between Familias Unidas plus PATH and ESOL plus HEART were reduced to non-significance. Analyses to determine whether parent-adolescent communication mediated the intervention effects on illicit drug use were not conducted because there were no significant differences between Familias Unidas plus PATH and ESOL plus HEART on parent-adolescent communication and no significant differences between Familias Unidas plus PATH and ESOL plus PATH on illicit drug use.

Substance Use Initiation: Smoking initiation rates were significantly different by condition, with fewer adolescents in the Familias Unidas plus PATH reporting initiating smoking during the course of the study, compared to adolescents in ESOL plus PATH and ESOL plus HEART. No significant differences in initiation were observed for alcohol use or illicit drug use.

Sexual Risk Behaviors: Post hoc analyses were performed to explore the differences by intervention condition on the incidence of STDs and two additional HIV risk behaviors measured by the Youth Risk Behavior Surveillance Survey: (a) unprotected sex at last sexual intercourse and (b) alcohol or drug use before last sexual intercourse. The incidence of STDs in Familias Unidas plus PATH was significantly lower than that for adolescents in ESOL plus PATH and ESOL plus HEART, although the number of participants that reported contracting an STD was quite small (n = 6 across all three groups). A significant difference also emerged in unsafe sex at last sexual intercourse between Familias Unidas plus PATH and ESOL plus PATH. No additional significant differences were found.

Study 3

This study meets Blueprints criteria, finding 30-month effects on substance use and condom use. It does not meet the criterion for sustainability as four booster sessions were delivered over time after the intervention.

Summary

Pantin et al. (2009) randomly assigned 213 eighth-grade students at-risk for problem behaviors in three Florida middle schools to treatment or control. Control families received three referrals to agencies in their catchment area that serve youth with behavior problems. Assessments were completed at baseline and at 6, 18, and 30 months post-baseline.

Pantin et al. (2009) found that the intervention group, relative to the control group, showed significantly

• Lower substance use at 30 months post-baseline.
• Higher condom use among sexually active youth from 6 to 30 months post-baseline.
• Greater improvements in family functioning (e.g., parent-adolescent communication, positive parenting, and parental monitoring of peers).

Evaluation Methodology

Design: Adolescents and their families were recruited from three large, predominantly Hispanic middle schools located within a single urban, low-income school district in Miami-Dade County, Florida. School counselors at each of the participating schools were asked to identify Hispanic 8th grade students who had at least "mild problems" on at least one of three Revised Behavior Problem Checklist (RBPC) subscales: conduct disorder, socialized aggression, and attention problems. Screening included a check for inclusion/exclusion criteria and completion of the RBPC subscales. Only adolescents rated by their parents as at or above one SD from the nonclinical normed mean on at least one of the three RBPC subscales were included in the study. Adolescents also had to be of Hispanic immigrant origin, to be in the 8th grade, to have an adult primary caregiver willing to participate in the study, and to live within the catchment areas of one of the three middle schools included in the study. Adolescents were excluded if the family was planning to move out of the catchment areas during the intervention period, the adolescent did not assent to participate, or scheduling conflicts prevented parents from participating in intervention sessions.

During recruitment, 531 potential participants were identified, of which 318 either refused or did not meet the eligibility criteria. There were 227 adolescents and their primary caregivers who completed baseline assessments, but only 213 were randomized to one of two conditions (it is unknown what happened to the 14 who were not randomized). There were 109 in the treatment group and 104 in the control group. Participants were assessed at baseline, randomized to either Familias Unidas or Community Control, and reassessed at 6, 18, and 30 months post baseline. The study used an intent-to-treat design. Familias Unidas families followed the intervention criteria explained in Study 1; community control families were given three referrals to agencies in their catchment area that serve youth with behavior problems. These families had no other contact with the study, except for assessment activities.

Parent and adolescent assessments were conducted in the language of their choice using audio computer-assisted self-interviewing methodology. Families were compensated $20, $25, $30 and $35 for completing the assessment at baseline, and 6, 18, and 30 months post baseline, respectively. Families were also compensated $30 for transportation at each assessment point.

Sample: Participants were 136 boys and 77 girls (mean age of 13.8 years) and their primary caregivers (n=27 men, 186 women; average of 40 years old). Only 13.1% of the families reported household incomes of over $30,000 year. A slight majority (56.1%) of adolescents were born in the U.S. Immigrant adolescents (n=93) and parents were primarily born in Honduras (26.9%), Cuba (20.4%), and Nicaragua (16.1%). Of foreign born adolescents, 36.6% had been living in the U.S. for less than 3 years, 45.2% between 3 and 10 years, and 18.3% for over 10 years.

Baseline Differences: There were no significant differences at baseline by condition on any of the demographic characteristics, lifetime sexual behavior, unprotected sexual behavior in the past 90 days, and externalizing disorders. Family functioning differed significantly by condition.

Measures: Adolescents and parents completed a demographics form at baseline. Family functioning included five parent-reported indicators: parental involvement and positive parenting (both measured using the Parenting Practices Scale); family support (using the Family Relations Scale); parent and adolescent communication (measured using the Parent-Adolescent Communication Scale); and parental monitoring (assessed using the Parent Relationship with Peer Group Scale). Substance use was assessed using items similar to those used in the Monitoring the Future study. Sexual risk behaviors were measured using items from the Sexual Behavior instrument. Parent reports on the Diagnostic Interview Schedule for Children predictive scales were used to assess externalizing behavior problems.

Analysis: Growth curve analyses were used to estimate individual trajectories of change in an intent-to-treat analysis. Chi-square tests and ANOVAs were also utilized. Control variables were: baseline levels of substance use in the substance use growth curve analysis; baseline levels of family functioning in the family functioning analysis; and baseline levels of positive parenting and parental monitoring for the positive parenting and parental monitoring analyses, respectively.

Outcomes

Fidelity: Fidelity was assessed through videotaped sessions and was assessed as "considerably/good."

Posttest:

Substance Use. The proportion of youth reporting substance abuse in Familias Unidas increased from 15% at baseline to 21% at 6 months, and then remained stable with 25% of youth reporting substance use at the 30-month mark. In the control condition, 13% of youth reported substance use at baseline, whereas at 30 months post baseline, this proportion had increased to 34%.

Externalizing Behavior. There was no significant difference in the growth curves for parent-reported youth externalizing behaviors over time between the two groups, but there were significant differences in the overall prevalence across the two conditions.

Unprotected Sexual Behavior. There was no significant difference found in whether adolescents engaged in sexual intercourse across conditions. However, sexually active youth in the intervention group reported significantly increased levels of condom use from 6 months to 30 months post baseline compared with those in the control group.

Family Functioning. Parents in the Familias Unidas group reported significantly greater improvements in family functioning compared with the control condition; data suggests that family functioning mediated the effects of the intervention condition on substance use, but not unprotected sexual behavior.

Study 4

In contrast to prior studies, this randomized controlled trial investigated the efficacy of the family-based Familias Unidas program on preventing and reducing risky sexual behavior and substance use among Hispanic delinquent youth. The studies used a shorter implementation period of 3 months compared to usual 9 months. Prado, Pantin et al. (2012) studied the 3-month period after the intervention and focused on risky sexual behavior, while Prado, Cordova et al. (2012) studied the 9-month period after the intervention and focused on substance use.

Summary

Prado, Cordova et al. (2012) and Prado, Pantin et al. (2012) randomly assigned 242 delinquent Hispanic adolescents (age 12-17 years) to either the Familias Unidas intervention (N=120) or a community practice control group (N=122). The intervention sought to reduce past 90-day substance use, alcohol and marijuana dependence, and risky sexual behavior among adolescents and to improve family functioning. Assessments were conducted at baseline, posttest (6 months post baseline), and 9-month follow-up (one year post baseline).

Prado, Cordova et al. (2012) and Prado, Pantin et al. (2012) found that the intervention group, relative to the control group, showed significantly

• Lower illicit drug use
• Fewer alcohol dependence diagnoses
• More improvement in family functioning (e.g., parent-adolescent communication, positive parenting, and parental monitoring of peers).

Evaluation Methodology

Design: Recruitment/Sample size/Attrition: Referrals for the study came from Miami-Dade County's Department of Juvenile Services and from the Miami-Dade County Public School system (MDCPS). Recruiters screened a total of 446 self-identified Hispanic youth and their primary caregivers. Of these, 310 met the study's eligibility criteria (Hispanic, 12-17 years old, intention to stay in South Florida during the study period, delinquent). Of the 310 eligible participants, 68 (15.2%) refused to participate. The remaining 242 were randomized to one of the two study conditions.

Due to attrition, a slightly reduced number of 232 (96%) adolescents completed the posttest and 229 (95%) completed the follow-up assessment.

Study type/Randomization/Intervention: The study was a randomized controlled trial. Participants were randomly assigned to either Familias Unidas (N=120) or community practice (N=122).

Intervention group: Consistent with the ecodevelopmental theory, the Familias Unidas intervention aimed to reduce risky sexual behavior and substance use by improving family functioning. The Familias Unidas intervention, delivered by trained research assistants, included eight 2-hour group sessions and four 1-hour family visits administered over a 3-month period. The sessions were parent-centered and focused on positive parenting, family communication, parental monitoring, and adolescent substance use and risky sexual behavior.

Control group: Participants in the community practice control condition received standard care services available to youth and parents of delinquent youth in Miami-Dade County. Services provided included both individual and family therapy.

Assessment: Both parents and adolescents completed questionnaires using an audio-enhanced, computer-assisted self-interviewing (audio-CASI) system. Assessments were conducted at baseline, posttest (3 months after the intervention), and follow-up (9 months after the intervention). Individuals supervising the data collection process were blind to the condition assignments.

Sample Characteristics: The study population was predominantly male (64%), with a mean age of 14 years. About 65% of the adolescents were born in the U.S. Immigrant adolescents (n = 84) and parents were primarily born in Cuba (25.0%), Honduras (15.5%), Nicaragua (9.5%), Puerto Rico (8.3%), and Dominican Republic (7.1%). Twenty-three percent of all the adolescents reported speaking mostly English, 43% reported speaking mostly Spanish, and 35% reported speaking both English and Spanish at home. In terms of acculturation, most youth reported being assimilated (46%; n = 108) or bicultural (48%; n = 112). Most of the youth (60%) came from families of relatively low SES, as indicated by a family income below $20,000 per year. About half (51%) of the adolescents were sexually experienced at the time of the pretest assessment.

Measures: Validity of measurements: The primary measures had been used by other researchers in published work.

Primary outcomes: Risky sexual behavior was measured using a number of posttest items:

• Whether adolescents had sex during the past 90 days.
• Whether adolescents had used a condom during their last sexual intercourse; a measure of "inconsistent condom use" was derived from responses to this item.
• How often adolescents had used condoms during sexual intercourse in the past 90 days.
• How many days adolescents were under the influence of alcohol or drugs and engaged in sex without a condom.
• The number of sexual partners in the past 90 days.

The follow-up used three measures:

• Substance use based on asking adolescents whether they had drank alcohol, or used an illicit substance in the 90 days prior to assessment. Binary variables were created to indicate any alcohol use and illicit drug use in the past 90 days.
• Alcohol dependence and marijuana dependence using adolescent reports on the Diagnostic Interview Schedule for Children (DISC) predictive scales. There are established cutoff scores that have been found to be predictive of formal alcohol dependence or marijuana dependence diagnoses.
• Whether the adolescents had sex in the past 90 days or in their lifetime when under the influence of sex or drugs.

Secondary outcomes (mediators): Family functioning was assessed using an index composed of 3 sub-scales:

• Parenting Practices Scale: used to assess parents use of positive affirmations and appraisal; 9 items, alpha=.72.
• Parent-Adolescent Communication Scale: used to assess the extent to of open and honest communication; 20 items, alpha=.77.
• Parent Relationship with Peer Group Scale: used to obtain parent reports of parental monitoring; 5 items, alpha=.84.

Secondary outcomes (moderators):

• Parental stress using the Hispanic Stress Inventory. Parents were asked to indicate whether, and the extent to which, in the past 6 months, they had experienced stressors related to occupational/economic, parental, family, culture, marital, and immigration processes. A parental stress total score was derived by summing all 73 stress items. Cronbach's alpha for the total parental stress score was 0.93.
• Social support for parents using the Social Provisions Scale. The 24-item measure assessed five domains of social support: guidance, reliable alliance, reassurance of worth, attachment, and integration. A total social support score was created by summing 24 support items. Cronbach's alpha for the social support for parents scale is 0.91.

Analysis: The posttest analysis (Prado, Pantin et al., 2012) employed Generalized Linear Models (GLMs) to compare the differences between the Familias Unidas intervention and the community practice control group in HIV sexual risk behaviors and family functioning. The models controlled for the corresponding baseline scores. Only participants who reported having had sex in the past 90 days were included in the analyses of sexual risk behaviors in the past 90 days.

The follow-up analysis (Prado, Cordova et al., 2012) used growth curve modeling to test for differences across the conditions in individual trajectories in the outcomes over all three time points (pretest, posttest, follow-up). The estimates used full information maximum likelihood techniques to include missing data (under the assumption that the data are missing completely at random or at random). Only sexually active youth are included in the analysis of having sex under the influence of alcohol or drugs.

To test for moderation, Prado, Cordova et al. (2012) estimated separate growth curve models for groups with low and high social support from parents and for groups with parents experiencing low and high stress.

Intention-to-treat: The study gathered and used data on the majority (96%) of subjects who were initially randomized, and on all subjects willing to participate at posttest.

Outcomes

Implementation fidelity: To assess fidelity, all sessions in the Familias Unidas intervention were videotaped and independent raters rated all of the group sessions and 25% of the family visits. The raters assessed whether the facilitator had attempted to complete the behaviors/practices during the group sessions as detailed in the program manual. Ninety-one percent of the behaviors were adhered to, indicating a high level of implementation fidelity.

Administered over a 12-week period, the intended dosage for participants included eight 2-hour multi-parent group sessions and four 1-hour family visits. The actual mean number of sessions attended was 6.88. Among those who attended at least one session (87%), the mean number of sessions was 7.9.

Baseline Equivalence: Prado, Pantin et al. (2012) failed to test for baseline equivalence, but Table 1 (p. 130) reveals some substantial differences in sociodemographic and behavioral characteristics. For example, of foreign born participants in the intervention group, 26.7% had been living in the U.S. for more than 10 years, while only 12.8% of the foreign born population in the control group had been living in the U.S. for more than 10 years. With regard to the outcome measures, a lower number in the intervention group (18.8%) reported unprotected anal sex at last sexual intercourse compared to the control group (42.9%).

Prado, Cordova et al. (2012) largely rectify this gap. They found no significant baseline differences across conditions on any of the demographic characteristics, past 90 days substance, alcohol, and illicit drug use, marijuana dependence, or having had sex under the influence of drugs and alcohol in the past 90 days. However, a higher proportion of youth in Familias Unidas had an alcohol dependence diagnosis. In examining growth curves from baseline and allowing for a correlation between the intercept and slope variance components, the models control for this baseline difference. However, the analysis of baseline equivalence did not examine the measures in Prado, Pantin et al. (2012) that showed the large deviations.

Differential attrition: Attrition was low, only 5% at follow-up. A chi-squared test for differential attrition was performed. The attrition rate did not differ significantly across the two conditions at posttest (5.8% for Familias Unidas and 2.5% for community practice) or follow-up (5.8% for Familias Unidas and 4.9% for community practice). Also, comparing completers and dropouts showed no significant differences on demographic variables or baseline outcomes.

Posttest (Prado, Pantin et al., 2012): Primary outcomes: HIV sexual risk behaviors. At posttest there were important differences between intervention and control group in inconsistent condom use in the past 90 days. Youth that received the Familias Unidas intervention were significantly (p<.05) less likely to report inconsistent condom use during vaginal intercourse (39% reduction; RR=.61) and anal intercourse (60% reduction, RR=.40), respectively. In addition, the mean number of days youth were under the influence of drugs or alcohol and had sex without a condom decreased in the intervention group from 2.05 days at baseline to 1.65 days at posttest whereas it increased from 0.39 days to 3.50 days in the control group (IRR=.36, p<.05). Also, adolescents in the intervention group reported lower numbers of sexual partners (IRR=.35, p<.05). Finally, there was a significant difference in the number of youth reporting unprotected anal sex at the last sexual intercourse. Only 17% of youth in Familias Unidas reported unprotected anal sex at last sexual intercourse, compared with 69% of youth in the control group (RR=0.24, p<.05). Thus, out of 8 tests, 5 (63%) were significant.

Secondary outcomes: Family functioning variables. Overall, families in the intervention group scored significantly higher (p<.05) on the family functioning scale. More specifically, parents in Familias Unidas reported significantly higher levels of parent-adolescent communication (adjusted mean difference = 2.51) and positive parenting (adjusted mean difference = 0.77) relative to the control group. No significant difference was observed for parental monitoring of peers.

Nine-Month Follow-Up (Prado, Cordova et al., 2012): The analysis examined three outcomes.

First, for substance abuse, growth curves for the conditions differed significantly. The proportion of youth reporting substance use (alcohol or drug use) in Familias Unidas decreased from 44.4% at baseline to 33.3% at follow-up, whereas the proportion reporting substance use increased from 38.8% to 45.5% for youth in community practice. Additional analyses found that the significantly greater improvement occurred for drug use but not alcohol use.

Second, growth curve analyses indicated a significantly different change in the percentage of youth with an alcohol dependence diagnosis. The percentage of adolescents with an alcohol dependence diagnosis decreased from 15.8% to 5.4% for Familias Unidas, while it increased from 6.6% to 8.1% for Community Practice. No significant intervention effects were found for marijuana dependence.

Third, growth curve analyses showed a significantly different change in past 90-day having had sexual intercourse under the influence of alcohol or drugs. The proportion of sexually active youth reporting having had sex while under the influence of alcohol or drugs increased from 12.5% to 34.9% in youth randomized to Community Practice but showed no change in youth randomized to Familias Unidas.

Tests for moderation showed significant results for only 2 of 12 interactions tested. For the alcohol dependence outcome, the program worked for youth with low social support from parents but not for youth with high social support. For the illicit drug use outcome, the program worked for youth with high parental stress but not youth with low parental stress.

Study 5

The structure of the Familias Unidas program was shortened in this study, though it appears the content was unchanged. As such, this may not be considered a true replication of the original program.

Summary

Estrada et al. (2015) randomly assigned 160 ninth-grade Hispanic students to either a shortened 6-week Familias Unidas intervention condition (N=72), or a community-practice control group (N=82). Assessments were completed at baseline and at 6, 12, and 24 months postintervention.

Estrada et al. (2015) found that the intervention group, relative to the control group, showed significantly

• Lower rate of sexual initiation rate
• Improved adolescent-reported positive parenting scores at 6-month follow-up.

Evaluation Methodology

Design:

Recruitment: Latino youth and parents were recruited in 2011 for the randomized controlled trial through four Florida public high schools for a total of 160 families.

Assignment: The families were randomly assigned to either the Familias Unidas intervention condition (N=72) or the community practice condition (N=88). The community practice condition functioned as a control group and consisted of the school-based HIV risk-reduction that is offered to all students and delivered by health science teachers in classroom format.

Attrition: Participants were assessed at 6, 12, and 24 months from baseline (or at 6-month posttest, 6-month follow-up, and 18-month follow-up). Between baseline and follow-up, the intervention group had an attrition rate of 12.5%, and the control group a rate of 11.4%.

Sample:

The sample had an average age of 15.3, was 51% male and 54.5% natural born citizens, and a majority had a family income <$30,000 (86%). Foreign-born participants and their parents were predominantly born in Cuba (37%), Honduras (12.3%), and Nicaragua (9.6%). Most caregivers' preferred language was Spanish (89.4%), while most adolescents preferred English (73.1%).

Measures:

All measures came from adolescent self-reports.

Adolescent substance abuse was assessed using an adapted instrument that indicated any substance use in the previous 90 days, as well as lifetime numbers for cigarettes, alcohol, and other drugs. Adolescent sexual risk behavior was assessed using another adapted instrument that indicated whether adolescents had engaged in sexual activity in their lifetime, and the frequency of condom use during sexual activity during the 90 days prior to assessment. Parental involvement (α=.86) and positive parenting (α =.80) were measured with the Parenting Practices Scale, and parent-adolescent communication (α=.91) was measured with the Parent-Adolescent Communication Scale.

Analysis:

The analysis used growth curve modeling to estimate individual trajectories of change from baseline and to test for condition differences over time. Regression analyses were used to examine intervention effects on the family functioning variables. Moderation analyses included the main effects of condition, the potential moderator (age, gender, baseline parental involvement, positive parenting, and parent-adolescent communication) and the interaction term.

Intent-to-Treat: The authors did not discuss whether they dropped missing data or used maximum likelihood estimation to account for the missing data, but noted that "for each of the outcomes included in the analyses, data from all four assessment time points were used." This could imply that they used all data from all time points, or that they only analyzed cases with data at all four time points.

Outcomes

Implementation Fidelity: The authors made no mention of implementation fidelity.

Baseline Equivalence: Baseline equivalence was established on demographic and outcome variables; there were no significant differences by condition at baseline.

Differential Attrition: Attrition analyses revealed no significant difference in the attrition rates across the two conditions. However, the study did not test for differential attrition by baseline measures or by condition-times-baseline measures.

Posttest and Long-term:

Primary outcomes:

From baseline to 18 months postintervention, the program showed no improvement on curbing unsafe sex practices, but youth in the intervention group showed a significantly lower sexual initiation rate (34%) compared to the control group (55%) at the last assessment. There were no significant differences in substance use or substance use initiation rates between the intervention and control groups. At the 6-month follow-up youth in the intervention group scored significantly higher on the positive parenting scale, but it is not discussed whether this continued to 24 months.

Moderating effects:

Gender: The program was more effective at preventing substance use initiation among girls in the intervention group (28.6%) compared to the control group (65.2%) than it was for boys. The program was also significantly associated with decreased alcohol use initiation among girls in the intervention group (30.4%) compared to the control group (64%).

Age: The program was significantly associated with reduced unsafe sex among adolescents aged 15 years or less, but not among older adolescents.

Parenting: Participants who reported low- to moderate-parental involvement at baseline showed significantly less use of illicit drugs. The program was effective at increasing positive parenting scores for adolescents who reported lot to moderate levels of positive parenting at baseline, but not among adolescents who reported high positive parenting at baseline.

Study 6

Like Studies 4 and 5, Estrada et al. (2017) and Vidot et al. (2016) used the three-month program (instead of the original nine).

Summary

Estrada et al. (2017) randomly assigned 746 eighth-grade Hispanic students to either a 3-month Familias Unidas intervention (N=376) or a prevention-as-usual control group (N=370). The authors assessed past 90-day substance use and risky sexual behavior at baseline, post-test, three, fifteen, and twenty-seven months afterward. A supplemental study (Vidot et al., 2016) explored the role of parent-adolescent communication on suicide thoughts and attempts.

Estrada et al. (2017) and Vidot et al. (2016) found that the intervention group, relative to the control group, showed significantly

• Less frequent drug use in past 90 days compared with control group
• Improved condom use in the last 90 days compared with control group
• Parental monitoring of peers and overall family functioning.

Evaluation Methodology

Design:

Recruitment: Estrada et al. (2017) examined students from 18 middle schools with Hispanic-majority student bodies in Miami-Dade County, Florida. Recruitment began in September 2010 while the intervention and follow-up proceeded through June 2014. Inclusion criteria required students to claim Hispanic origin, be enrolled in eighth grade, have a participating primary caregiver, live in the catchment area of a participating middle school, and plan to live in South Florida during the study. Of the 989 assessed, 746 were eligible.

Assignment: The authors used stratified randomization within school to assign the 746 students to the Familias Unidas intervention group or the "prevention as usual" control group.

Attrition: Participants were assessed at 6, 18, and 30 months from baseline. Given the 3-month program, the posttest came 3 months after the intervention ended, and follow-ups occurred 15 and 27 months after the intervention ended. Familias Unidas had a 13.3% attrition rate while prevention as usual had a 12.2% attrition rate. Vidot et al. (2016) reported overall retention rates of 93.4%, 90.5%, and 87.3% for each of the assessments.

Sample: Most students self-reported as slightly less than 14 years old (about 13.8 years). The sample had a majority proportion of males (52.14%) and students born in the US (54.83%).

Most parents (67.56%) reported earning less than $30,000 annually and being born in a Spanish-speaking country in the Americas. Mothers were more likely to participate (83%) and average parental age was 41.

Measures: Students self-reported substance use and sexual behaviors. Youth were asked about alcohol use in the past 90 days and in their lifetime, and about use of illicit drugs (e.g., marijuana, LSD, cocaine) in the past 90 days and in their lifetime. They also reported sex in the past 90 days and in their lifetime as well as frequency in the past 90 days of sex without a condom.

Parent responses assessed family functioning on three indicators: monitoring and knowing their youths' friends, using positive parenting practices (e.g., rewards, acknowledgement) to respond to positive behaviors, and family communication.

Additionally, Vidot et al. (2016) assessed student self-reported suicide ideation ("thought seriously about killing yourself") and suicide attempts ("tried to kill yourself in the last year"). They also used a 20-item parent-reported measure of communication with their child (alpha = .82).

Analysis: Outcomes were analyzed with linear growth curve models. The authors used time-varying zero-inflated Poisson growth modelling for continuous drug use outcomes, while the probit-LINK function (Mplus) was used to test binary outcomes for past 90-day alcohol use outcome. Vidot et al. (2016) also used growth curve models. Both studies adjusted for the clustering of students within schools.

Intent-to-Treat: All subjects were included in most analyses, with missing data addressed using FIML. Only those reporting past 90-day sexual activity were included in analyses for sex without a condom. Estrada et al. (2017) dropped seven student participants (<1%) from the analysis of drug use in the past 90-days for outlying or invalid response patterns.

Outcomes

Implementation Fidelity: Trained master's-level graduate students evaluated all videotaped group sessions and 25% of the family sessions using a 7-point scale. Twenty percent of rated sessions were also evaluated by a second independent rater (IRR > .80). Fidelity ratings were slightly higher for family visits (from 2.60 to 5.20) than parent groups (from 2.04 to 4.30) and averaged to 3.61, but both scores appear low. Also, parents attended 6.4 of 12 sessions on average, and 12.9% of participants attended no sessions.

Baseline Equivalence: Tests for baseline equivalence for 14 measures in Estrada et al. (2017) found two significant differences. The control student group was significantly more likely to report sex without condom use in the last 90 days than the Familias Unidas intervention group. Control parents also reported higher family communication than parents in the Familias Unidas group. Vidot et al. (2016) noted no differences in demographic or suicide characteristics.

Differential Attrition: Estrada et al. (2017) noted that attrition rates did not differ significantly across conditions, but they did not test for attrition differences by any of the baseline measures or their interaction with condition. Vidot et al. (2016) reported that the data were missing completely at random, but it is unclear if the tests included dropouts in each of the assessments.

Posttest and Long-Term: In Estrada et al. (2017), intervention students reported improved drug use frequency in the last 90 days compared with control students. Among those ever having had sex, control participants reported significantly greater increases in past 90-day sexual activity without a condom than intervention participants. The program did not significantly affect alcohol use or ever using drugs

Also in Estrada et al. (2017), parents of youths assigned to the Familias Unidas group reported greater oversight of their child's friends and greater family functioning compared with those in the control group at 6-month follow-up. In addition, parental peer monitoring significantly mediated the intervention effect on drug use frequency.

Vidot et al. (2016) found no program effects overall on suicide ideation or suicide attempts. They did find a significant positive effect on parent communication overall and a significant negative effect on suicide attempts but only for students with low parent-adolescent communication scores at baseline.

Study 7

Like Studies 4, 5, and 6, Molleda et al. (2016) used the three-month program (instead of the original nine). The program was adapted to fit the language and culture of Ecuador but without changing any of the core components.

Summary

Molleda et al. (2016) randomly assigned 239 families from two schools in Ecuador to the 3-month Familias Unidas intervention (N=129) or Community Practice control group (N=110). Data were collected at baseline and at the conclusion of the three-month program. The authors assessed parent reports of adolescent conduct problems and family functioning (parent-adolescent communication and parental monitoring of peers).

Molleda et al. (2016) found that the intervention group, relative to the control group, showed significant

• Reduction in conduct problems at three months
• Improvement in parent-adolescent communication.

Evaluation Methodology

Design:

Recruitment: The study examined students from two public schools in the largest city in Ecuador, both of which were located in neighborhoods associated with low income, high crime rates, and high risk of substance use. Recruitment was open to all students ages 12-14 who consented to participate, except those with prior psychiatric treatment. Of 248 screened, 239 were eligible.

Assignment: The 239 students were randomly assigned within schools to the Familias Unidas intervention group (N = 129) or the Community Practice control group (N = 110). The authors noted that the randomization was done "without stratifying by school" but do not explain the uneven number of subjects in each group.

Attrition: Participants were assessed at baseline and at the conclusion of the 3-month intervention. About 88.7% of the randomized subjects completed the posttest.

Sample: Most students self-reported as slightly less than 13 years old (about 12.87 years). Male participation (48.3%) was slightly less common than that of females. About one-third of parents were married (33.9%). Mothers were more likely to participate (93.7%), and average parental age was 37.21.

Measures: The outcome measures came from parents who were involved in the program and learned strategies for dealing with their children; none came from the adolescents. Parent responses assessed family functioning on three indicators: parent-adolescent communication, monitoring or knowing their child's friends, and conduct problem (open disobedience, defiance, oppositional disorders, physical aggression, and difficulty controlling anger).

Analysis: Outcomes were analyzed using a cross-lagged design to explore direct and indirect effects of the intervention on the family functioning measures. The model controlled for baseline outcomes, and estimates from MPlus used robust standard errors.

Intent-to-Treat: All subjects were included in the analyses, with missing data addressed using maximum likelihood estimation.

Outcomes

Implementation Fidelity: Trained staff members from the Catholic University of Santiago of Guayaquil evaluated all videotaped group sessions and 72% of the family sessions using a 7-point scale. Family sessions were rated slightly higher (4.58) than group sessions (4.5), though both session types suggest only modest fidelity to the program. Participants averaged attending 9.57 sessions of the 12 offered.

Baseline Equivalence: Table 1 shows no significant differences for six demographic and outcome measures, but the table did not include the peer monitoring measure.

Differential Attrition: The study did not test for attrition differences by any of the baseline measures or their interaction with condition.

Posttest and Long-Term: Intervention group assignment resulted in a significant and direct effect on conduct problems at posttest (d = -.262) and a significant direct effect on parent-adolescent communication. In addition, the mediation analysis found a significant indirect treatment effect predicting behavior problems at three months based on parent-adolescent communication at three months.