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J Child Fam Stud (2007) 16:531–544 DOI 10.1007/s10826-006-9104-3 ORIGINAL PAPER

Description of a Behavioral Intervention to Reduce Substance Use and Related Risk and Increase Positive Parenting among Urban Mothers with Alcohol and Other Drug Problems Noelle R. Leonard · Marya V. Gwadz · Gricel N. Arredondo · Marion Riedel · Lauren Rotko · Emily J. Hardcastle · Jodi C. Potere Published online: 21 December 2006  C Springer Science+Business Media, LLC 2006

Abstract The abuse of alcohol and other substances by mothers raising adolescent children has serious adverse effects on family functioning and youth outcomes, and on mothers’ own health and adaptation. Mothers who are also HIV-infected face additional challenges. In the present report, we describe a multi-session intervention conducted in individual sessions for mothers with alcohol and other substance use problems who are raising adolescent children. We outline the primary components of the intervention and include case studies and examples of exercises and tools. We found that engagement with the intervention and high rates of attendance were facilitated by tapping into mothers’ desires to improve their relationships with their adolescent children, the use of a harm reduction approach toward substance use, and intensive outreach. We also discuss lessons learned in the course of implementing and evaluating the intervention. Keywords Alcohol . Substance use . Mothers . Adolescents . HIV . Intervention Problem drinking by mothers is associated with disruptions in family functioning, poor parenting, and a wide range of negative psychosocial outcomes for youth (Chassin, Pitts, DeLucia, & Todd, 1999; Miller, Smyth, & Mudar, 1999), as well as poor health and mental N. R. Leonard () · M. V. Gwadz · G. N. Arredondo Center for Drug Use and HIV Research, Institute for AIDS Research, National Development and Research Institutes, Inc., 71 West 23rd Street, 8th Floor, New York, NY 10010, USA e-mail: [email protected] M. Riedel Columbia University School of Social Work, New York, NY, USA L. Rotko New York University School of Social Work, New York, NY, USA E. J. Hardcastle Psychology and Human Development Department, Vanderbilt University, Nashville, TN, USA J. C. Potere Graduate School of Social Service, Fordham University, New York, NY, USA Springer

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health outcomes for mothers (Wilsnack & Wilsnack, 1995). Women with problem drinking also commonly use other substances (Grella, Anglin, & Annon, 1996). While a mother’s problem drinking is a significant risk factor for developmental and adjustment difficulties among her children, these adverse effects appear to be even more pronounced when mothers have co-morbid alcohol and drug problems (Ohannessian et al., 2004). Problematic behaviors such as substance abuse, sexual risk behavior, and delinquency typically emerge or increase substantially during adolescence, indicating youths’ need for guidance and support (Chassin et al., 1999; Wills, Schreibman, Benson, & Vaccaro, 1994). Mothers’ alcohol and drug use compromises the quality of their parenting; for example, their consistency and predictability (Windle, 1996); their ability to supervise and monitor adolescents’ behaviors, and the establishment and enforcement of appropriate rules (Chilcoat & Anthony, 1996; Windle, 1996). Adolescents whose parents monitor them inadequately may begin alcohol and drug use at earlier ages (Chilcoat & Anthony, 1996), show more delinquent behavior (Forehand, Miller, Dutra, & Chance, 1997), and select more deviant peer networks (Dishion, Patterson, Stoolmiller, & Skinner, 1991). Parents with alcohol and/or drug problems are more likely to adopt harsh authoritarian, over-controlling or under-involved parenting styles, and provide lower levels of nurturing and emotional availability (Miller et al., 1999; Windle, 1996). Further, substance use often exacerbates mothers’ pre-existing mental health conditions, which are also likely to negatively influence parenting (Galvan, Burnam, & Bing, 2003; Watkins, Burnam, Kung, & Paddock, 2001). Thus mothers’ substance use, and the mental health problems that commonly co-occur with that use, place their adolescent children at elevated risk during a critical developmental period. Furthermore, substance abuse disproportionately affects women who are poor, live in disenfranchised communities, and are from racial and ethnic minority backgrounds, all of which may be significant stressors (Lindenberg et al., 1999; Marcenko, Kemp, & Larson, 2000). In addition to the multiple contextual and psychosocial stressors affecting mothers with problem drinking and drug use, those who are also infected with HIV face additional personal and parenting challenges, including continuous management of their health and complex medical regimens, limited social support, and the stigma associated with HIV (Armistead & Forehand, 1995; Gwadz et al., 1999; Mellins, Ehrhardt, Rapkin, & Havens, 2000). Along with substance abuse, mental health problems, particularly depression and anxiety, co-occur with HIV infection (Klinkenberg & Sacks, 2004). Yet HIVinfected mothers tend to be more similar to than different from their demographically comparable HIV-uninfected peers in many areas of behavioral and psychosocial functioning (Leonard, Gwadz, Cleland, Rotko, & Gostnell, 2005; Moore et al., 1999; te Vaarwerk, & Gaal, 2001). This suggests that poverty and/or substance abuse are primary stressors for these women, and/or that they may successfully adapt to HIV infection over a period of time. Successful family-based interventions for preventing youth risk behaviors have been developed for families coping with parental HIV- infection (e.g., Rotheram-Borus et al., 2003), as well as for families coping with parental substance abuse (e.g., Aktan, Kumpfer, & Turner, 1996; Kelley & Fals-Stewart, 2002). These programs are designed to be delivered to parents and children in small multi-family group or couples’-based formats. While these modalities have advantages, their dissemination may be limited for mothers whose childcare responsibilities and/or ill health make it difficult, for example, to attend weekly sessions. The stigma attached to HIV and substance abuse also discourages participation in groups where these conditions would be disclosed to other adult participants and/or adolescent children (Copeland, 1997). Interventions conducted with mothers in individual sessions eliminate these barriers. Further, mothers’ alcohol and drug problems tend to be Springer

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long-standing and resistant to change, signaling the need for innovative intervention approaches (Culverhouse et al., 2005). The social networks of mothers with alcohol and drug problems play an important role in shaping their abilities to manage substance-related risk, maintain their health, and parent their adolescent children. Thus, it is vital to develop strategies that go beyond individually-oriented skill acquisition, particularly for minority women living in disenfranchised communities that expose them to multiple stressors including a high prevalence of substance use among their social network members. Strategies for behavior change that involve social network members are likely to enhance the longevity of intervention effects. The aim of the present paper is to describe the Family First program, a behavioral intervention for urban mothers coping with alcohol and other substance use problems who are raising adolescent children. Family First has two primary targets: reducing or eliminating mothers’ substance abuse and/or the associated risks, and improving the quality of parenting provided to adolescent children. A secondary aim is to assist mothers in reducing or eliminating their sexual risk behavior that might transmit HIV to others and/or result in the mothers’ acquisition of other sexually transmitted infections or strains of HIV. While we initially developed the intervention program to address the needs of HIV-infected mothers, the final version was developed for, and successfully delivered to, both HIV-infected and HIV-uninfected mothers with problem drinking and other drug use. We review the theoretical frameworks guiding the intervention’s approach and content; provide an in-depth description of the intervention’s elements and characteristics, with illustrative case examples; and discuss the lessons learned in the course of delivering the intervention. The Family First intervention is grounded in two effective intervention approaches for problem drinking: cognitive-behavioral skills therapy (CBST) (Longabaugh & Morgenstern, 1999; Project MATCH Research Group, 1997), and Motivational Interviewing (MI) (Burke, Dunn, Atkins, & Phelps, 2004; Hettema, Steele, & Miller, 2005). The intervention also applies these frameworks to improving parenting. CBST is based on the principles of social learning theory and conceptualizes problem behavior as functionally related to major stressors and problems in an individual’s life. MI approaches seek to improve readiness to change, while CBST targets change processes (Burke et al., 2004; Hettema et al., 2005). In order to address particular issues affecting urban mothers with problem drinking, and to boost engagement, efficacy, and longevity of effects, we integrated these evidence-based approaches with theoretically-based elements that target social forces which might impede or promote behavior change, drawing on Social Action Theory (SAT) to do so (Ewart, 1991). A variant of social-cognitive theory that incorporates motivational elements and is congruent with harm reduction, SAT is the over-arching theory guiding the intervention. SAT is an integrative model that identifies both individual and social-contextual influences that can be modified to encourage health-protective behaviors. Health habits, such as substance use or poor parenting skills, are framed as an organized system of routinized sequences of actions, consequences, and reactions that lead to predictable outcomes. These routines are typically socially interdependent in that they are interlinked with the behaviors of others. To encourage behavior change, SAT calls for targeting both contextual influences, such as mental health symptoms, and self-change processes; specifically, motivation, social interaction processes, and coping skills. Motivation to act is expected to improve as personal feedback regarding alcohol/drug use and parenting concerns is provided. Mothers with alcohol and drug problems typically require coping skills training to better manage the situations, places, persons, and actions that may elicit problem alcohol/drug use, poor parenting, or sexual risk behavior. Identification and understanding of social networks, and strategies to engage these networks, are important components of SAT. Under the rubric of SAT, social learning theory Springer

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(Bandura, 1986) provides a framework for how individuals change their behavior: small, well-articulated behavioral goals are set; self-reward mechanisms are developed to reinforce change; skills needed to meet goals are identified and learned; and self-efficacy is supported. Alcohol and other substance use treatment outcome studies typically enroll patients presenting for treatment (Morley, Finney, Monahan, & Floyd, 1996). Yet many, perhaps the majority, of those with alcohol and drug problems are unwilling, unable, or not ready to enter a treatment or commit to abstinence at any given time. Strategies to engage these individuals in services, build motivation for behavior change, and treat them in their present state of readiness are needed. Thus, we incorporated a harm reduction approach which enables individuals to develop individualized goals related to substance use without necessarily eliminating substances from their lives (Denning, 2000). This approach includes, rather than opposes, abstinence and can serve as a transition to future abstinence outcomes (Marlatt, Blume, & Parks, 2001; Springer, 1996). Harm reduction techniques have had a demonstrated positive effect on reducing smoking risks (Britton, 2003) and reducing the quantity of drinking in adults (Humphreys, 2003).

Method Participants were recruited from hospital-based health and HIV/AIDS clinics, AIDS Service Organizations, media ads, and through the social networks of eligible participants; thus, most mothers were not seeking treatment for alcohol or drug problems at the time of recruitment. Women were eligible if they (a) were the biological or adoptive mother of at least one adolescent child between the ages of 11 and 18; (b) resided with at least one of these adolescent children at least half the time over the past month; (c) scored a six or higher on the Alcohol Use Disorders Identification Test (AUDIT) (Bohn, Babor, & Kranzler, 1995) which indicates problematic alcohol use for women based on quantity, frequency, and associated problems; (d) and did not inject drugs during the past three months, because the intervention did not incorporate the most effective strategies for injection drug users such as combined behavioral and pharmacologic treatments (O’Connor & Fiellin, 2000). Women with recent injection drug use were referred to local programs. Five hundred and seventy-seven women were screened (61% HIV-infected) and a total of 128 met eligibility criteria (22.2%). (Over 90% of the women who were not eligible had AUDIT scores of less than 6.) Of these, 118 women (55% HIV-infected) completed baseline interviews and were randomly assigned to receive the 14-session Family First intervention or a one-session brief motivational control intervention. Mothers signed informed consent prior to participation; the instruments, recruitment procedures, and intervention curricula were approved by the Institutional Review Boards of NDRI, Inc. and the participating sites. The Family First intervention curriculum was based on two evidence-based programs: the cognitive-behavioral coping skills training (CBST) arm of Project MATCH (Monti, Abrams, Kadden, & Cooney, 1989) for alcohol and drug use, and the Family Management Curriculum of the Adolescents Transitions Program (Dishion & Kavanagh, 2004). The Family Management Curriculum is delivered to parents of high-risk adolescents (without their children present) and focuses on training parents to provide incentives for behavior change, develop skills in limit setting and monitoring, and improve the parent-child relationship. It views parental monitoring as a key construct in improved youth outcomes (Dishion & McMahon, 1998). We conducted qualitative research with members of the target population in order to adapt both existing curricula, pilot tested drafts of the intervention, and revised as needed (intervention curriculum is available from the second author). Springer

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The intervention was delivered by multi-racial female master’s-level clinicians with previous supervised training in psychotherapy. Facilitators received a standardized 36-h training. All sessions were audio-taped for supervision and quality assurance. Facilitators received weekly individual and monthly group supervision that focused on maintaining fidelity to the intervention while individualizing session content; overcoming barriers to implementation, and providing effective harm reduction treatment. Participants were primarily from racial and ethnic minority backgrounds: 56.8% were African-American, 28% were Latina; 5.9% were White; 9.3% were multi-racial or other ethnicities. Most were low-income (88% on Medicaid); close to 65% reported a history of homelessness and over 68% had been arrested one or more times. The mean age was 40.4 years (SD = 6.16; range 27–54); 55% were HIV-infected by self-report. Mothers had a mean of 2.3 adolescent children ranging in ages from 11 to 18. Close to 29% of mothers reported that one or more of their children had spent some time in foster care in the past. For HIV-infected mothers, the mean time since HIV diagnosis was 9 years (SD = 4.4; range: 1–20 years). Over one third had been diagnosed with AIDS (38.7%). The majority (87.3%) reported having one or more HIV-related symptoms in the past six months. 57 (48.3%) were randomly assigned to the Family First intervention condition. Over the past 6 months, prior to the baseline interview, mothers averaged 6.56 (SD = 7.85) drinks per day. Most (70%) used other drugs (primarily marijuana and/or cocaine) in addition to alcohol. A total of 19% of the sample was infected with the Hepatitis C virus (26% of HIVinfected and 9.4% of HIV-uninfected). There were few differences between HIV-infected and HIV-uninfected mothers; the majority fell well below the normative mean on standardized self-report measures of general physical and mental health (Leonard et al., 2005). The intervention consisted of 14 one-on-one counseling sessions, each lasting approximately 1.5 h. Most participants (98%, 56/57) attended at least one intervention session, and the majority (77%; 44/57) attended all 14 sessions, with an average participation rate of 12 sessions. Sessions were scheduled at participants’ convenience, including evenings and weekends. Cancellations and missed sessions were common and participants were offered multiple opportunities to re-schedule. The length of time between each participant’s first and last intervention session averaged slightly over 20 weeks (SD: 12.25; range: 0–59.4 weeks). Retention was maintained through multiple outreach activities including phone calls, letters, and addressing barriers to attending. Participants received a stipend of $20 per session plus public transportation costs.

Description of intervention sessions Each intervention session focuses on a specific topic and set of skills. Sessions follow a general framework which begins with a “check-in” and homework review, an introduction to the session topic, a video-taped role model story linked to the session topic (described below), skill building modeling and instruction, practice of the skill, and real-life application of the skill through homework. In each session, a relaxation technique is used to assist mothers in coping with the potentially affect-laden material elicited by the curriculum. This relaxation exercise also provides mothers with a coping skill for affect management outside of the sessions. Early in the intervention, mothers are assisted with setting a realistic goal to reduce or eliminate alcohol and/or drug use, and/or the associated harms. This goal is reviewed in subsequent sessions, with an emphasis on progress achieved between sessions, and a determination whether the goal needs modification. Sessions are flexible in order to individualize the curriculum for each participant while maintaining fidelity to the intervention Springer

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J Child Fam Stud (2007) 16:531–544 Video role model stories

Video Role Model Story, Part I, Session 3 Script of video role model story Part I, Session 3 I was very close with my father, and when he passed away I started drinking a lot. I started spending so much of my money on alcohol that my children weren’t getting the things they needed. I used to buy my daughter something small on check days, and when I stopped doing that, my daughter was like, “What’s up, ma?” I would tell her I had to spend the money on other stuff, but I knew she saw what was going on. She would say, “Well, the electricity was shut off . . .” So, at that point, I decided I had enough, and I was not going to drink again. But that turned out to be a failure, because nothing else in my life had changed, and I wasn’t really ready to stop drinking. So, I decided to set some smaller goals for myself. I decided I would have 3 drinks for the day, and pay one of the bills. I did this for awhile and it was o.k. So, I decided then that I would have 2 drinks for the day, pay a different bill, and then go buy some food for my kids. And I’ve been doing this a couple of weeks now, and it has been o.k. Video Role Model Story, Part II, Session 9 Script for Video role model story Part II, Session 9 Recently I’ve been trying to get myself together. I stopped using, I started taking my medication and going to see the doctor on a regular basis. You know I’m trying to make every effort to take care of myself and my children and overall things are pretty good. But, sometimes it gets a little hard. Like I was talking to my sister, cause all my kids have developed an attitude. You know like they don’t respect me. Don’t get me wrong, I know they are proud of me, but sometimes they act up. Well my sister had to remind me that when I was out using I wasn’t there for my kids. You know they had to take care of themselves and they are hurt about it. And they’re angry. I realize she’s right. But I thought because I was better, they were better. Well now I know it’s gonna take a little more time. Now I am trying to do everything right so that we can be a family.

manual. Thus, the acquired skills are applied to mothers’ individual circumstances, such as overcrowded apartments, or changes in family structure. Video-taped role model stories (Corby & Wolitski, 1996) are used in each intervention session for two primary purposes: first to “problematize” issues (e.g., alcohol use and ability to monitor adolescent children) and second, to model risk-reducing behavior and parenting skills with positive outcomes. These gender-tailored and culturally relevant stories were based on qualitative interviews with members of the target population and edited to fit the role model format, using actresses to portray mothers (Table 1; see www.cduhr.org for examples). Part I: Reducing alcohol and drug use and/or associated harms The seven sessions in Part I are designed to (a) build motivation for changing alcohol and drug use or abuse patterns; (b) develop a realistic behavioral risk reduction goal; (c) identify members of the mother’s social networks who can assist her in her goal; (d) learn strategies for enrolling members of social networks effectively; and (e) learn strategies to cope with triggers for substance use and attendant feelings. Building motivation and setting goals Recognizing that participants were not necessarily seeking treatment, Part I helps mothers identify their own concerns about their substance use in order to set individualized goals. The role model stories throughout this phase portray mothers at varying levels of readiness to Springer

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change. Moreover, facilitators’ unconditional acceptance of mothers’ goals is a key ingredient for assisting mothers in focusing on the harms associated with their substance use. We also viewed the participants’ roles as mothers as a powerful incentive for changing substance use patterns. The inter-relationships among substance use, health, mental health, parenting, and child functioning were themes underlying each session. While setting a substance use goal is a key component of Part I, mothers are not asked to do so prematurely; first, motivation to make behavioral changes regarding substance use patterns must be established. Thus, in Session 1, mothers explore their values by taking inventory of various aspects of their life (e.g., substance use, romantic relationships, parenting), in particular, aspects they are interested in changing, and the people in their social network involved in each area. For HIV-infected mothers, information about the deleterious effects of using alcohol while taking anti-retroviral therapies is also reviewed. The elements of this session are intended to foster a relationship between the participant and the facilitator, emphasize the mother’s resources and strengths, and build motivation for behavior change. In Session 2 mothers receive personal feedback about the quantity and frequency of their alcohol and drug use, the related problems they identified, and how their use translates into the amount of money they spend on substances and the number of calories they are consuming. This strategy is intended to further boost motivation for behavior change and set the stage for goal setting. In Sessions 2 and 3 mothers explore discrepancies between their values and their behavior, and how these behaviors are linked with the actions of others. Capitalizing on the ambivalence that arises when discrepancies are identified, facilitators assist mothers in conducting a decisional balance exercise to identify the pros and cons of changing an identified risk behavior, and of not changing it (Miller & Rollnick, 2002). The identification of people in mothers’ social networks who might help them to make changes, as well as those who might hinder change also serves to increase mothers’ motivation. This exercise helps to set the stage for the development of a realistic substance use reduction or risk reduction goal which incorporates supportive others. Cheryl (pseudonyms are used for each case study) is a 43 year old HIV-infected mother who lives with her 16 old daughter, Sharone. Over the past few years Cheryl had substantially reduced her use of marijuana, cocaine, and alcohol. However, she continued to be concerned about her alcohol use, particularly when she goes out to clubs. Cheryl shared a recent drinking episode that “scared her.” The morning after a recent outing, her daughter expressed concerns about her whereabouts. Because Cheryl had little memory of what occurred the night before, she yelled at Sharone, stating that her whereabouts were “none of Sharone’s business.” She reported feeling guilty about her interaction with Sharone and felt that this incident demonstrated that she lacked the ability to control her drinking. By the end of the session, Cheryl set a risk reduction goal: she would plan to have a maximum of two drinks when she went out with her girlfriends to clubs. She articulated this goal to her friends and elicited pledges of support, although they cautioned her that they had no intentions of sharing her goal.

Development of coping skills Throughout the intervention, mothers learn and practice cognitive-behavioral coping skills including relaxation techniques; scaling and labeling emotions (using a “feeling thermometer”); identifying personal triggers for substance use; understanding the relationships among thoughts, feelings and behavior; and social problem-solving techniques. Springer

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Angie had two adolescent children, ages 12 and 17. She identified her ex-boyfriend, Darrell, as a trigger for using cocaine. Using social problem solving techniques, Angie brainstormed actions she could take to prevent cocaine use. These included telling a friend about her goal, using self-talk to remind herself of her goal, and using relaxation techniques to manage her anxiety. After seeing Darrell at a club one night, she went to the bathroom and did some relaxation techniques which served to remind her of her goal to avoid cocaine use. Engaging the social network Sustaining behavior change and self-protective action requires changing highly inter-linked habitual social routines. As the above examples illustrate, mothers’ substance use patterns are heavily influenced by, and entwined with, members of their social network. Thus, in addition to learning individual coping mechanisms, mothers require training to change relational patterns and enlist support for behavior change. Session 4 focuses on increasing effective communication skills with social network members, both to enlist those people mothers believe will support their risk reduction goals, and to renegotiate relationships with those they feel would hinder their goals. In this session, facilitators model and train mothers on skills such as paraphrasing, reflective listening, and using I-statements. Natalie identified being around people who used crack as a trigger for her own use. Her goal was to avoid people who used crack, which included not allowing friends who used crack into her apartment. At one point during her participation in the intervention, Natalie’s partner, Lloyd, came home with crack and the two of them used together. Afterward, Natalie was furious and threw Lloyd out of the apartment. With coaching from the facilitator, Natalie calmly articulated her disappointment to Lloyd about his bringing drugs into the home and the two of them negotiated a joint risk reduction goal for Natalie to avoid crack use, where he would refrain from suggesting that she use crack with him, or use it in her presence. Reducing sexual risk behaviors In Session 6, mothers identify their individual sexual risk behaviors and triggers for engaging in unprotected sexual behavior. Mothers also learn refusal skills and review effective communication skills for use with sexual partners. The last session in Part I comprises a review of the skills learned and identification of barriers mothers may be encountering in the course of achieving their goals. Slips and relapse are discussed as part of the process of change and mothers identify the triggers that might lead to a slip or relapse and develop a plan to deal with these triggers. Part II–Improving the quality of parenting Part II primarily focuses on increasing positive parenting skills with adolescent children. Its seven sessions are designed to (a) build motivation for addressing parenting behaviors; (b) develop a realistic parenting behavior goal or set of goals; (c) identify members of mothers’ social networks who can assist in their goal(s); (d) learn strategies for involving members of social networks effectively; (e) develop behavioral management skills to achieve positive child outcomes, including better parental monitoring, improved communication, and setting up a family management system in the form of a behavioral contract. To foster the internalization of intervention components, many of the skills learned in Part I are tailored for use in Part II. The intervention incorporates family management strategies within the SAT Springer

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conceptual model. Although the primary focus is on parenting, each session in Part II begins with a brief review of the mother’s progress on her substance use goal. Coping strategies such as relaxation and the feeling thermometer continue to be used to assist mothers in dealing with the powerful emotions associated with parenting. The impact of HIV and/or substance abuse on parenting Many of the sessions in Part II focus on the impact of mothers’ health and/or substance use on their ability to effectively track and monitor adolescents’ behavior. Because many HIV infected mothers made significant positive life changes after their diagnoses, building on these strengths is an important aspect of engaging mothers in considering alternate parenting strategies. The role model story in session 9 (Table 1) illustrates the historical negative impact of a mother’s substance use on her children. Increasing motivation and setting a parenting goal Facilitators provide feedback to mothers on the parenting challenges and child problem behaviors they identified in the baseline interview, and highlight their self-identified strengths. Mothers are asked to describe their emotionally charged responses to adolescent behaviors and how these impact their ability to parent effectively. Using the goal setting framework, mothers articulate a child’s behavior (e.g., attending school) that they wish to address and facilitators assist mothers in breaking down this behavior into realistic, observable, and measurable steps. Tracking and monitoring target behaviors Subsequent sessions develop strategies for tracking and monitoring these behaviors such as using a tracking form, gathering information, and questioning techniques. In sessions, facilitators review mothers’ progress and revise and expand target behaviors as necessary. Communication Mothers role-play using the positive communication strategies learned in Part I in a manner that is appropriate with their adolescent children. A number of mothers described that they resorted to yelling at their adolescents, which typically resulted in verbal and sometimes physical altercations. Mothers learn how they can use two key strategies, neutral requests and verbal praise, to engage in more positive dialogue with their adolescents. Facilitators assist mothers in rewording requests to make them less emotionally charged, such as, substituting statements that encompass blame and past behaviors (e.g., “you never clean the kitchen”) with statements that request a specific behavior (e.g., “please sweep the floor”). Felicia had two children ages 10 and 13. In order to get them to do household chores she would start by requesting several times, but typically she would then raise her voice and threaten to take away privileges. She found this both ineffective and tiring. Felicia was presented with the skill of using neutral language to make requests to her children but felt it would undermine her authority: if they didn’t listen to her when she raised her voice, she thought it even less likely that they would respond to a neutral tone. She agreed, however, to give it a try. Over a number of weeks, Felecia used the strategy and found that her children tended to comply with her requests and that the approach was less taxing to her. Springer

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Behavioral contracts Participants learn to set up a family management system in the form of a behavioral contract with their adolescent children. Facilitators and mothers develop a list of possible positive consequences for performing a desired behavior, such as food (selecting the evening’s meal), activities mothers and adolescents do together (e.g., manicures, playing a video game), privileges (e.g., having a shared bedroom to him/herself for a period of time), as well as those that cost money (e.g., new clothes, videogames, etc.). Monique acknowledged that due to family stressors, she had difficulty maintaining limits and consequences. She said she felt guilty about her inability to be with her children in the past as a result of alcohol abuse and poor health, and felt that she wanted to “make up” for it. While she commonly threatened her children with negative consequences, Monique often did not follow through on them, particularly when she was not feeling well. Monique recognized that her son’s behavioral difficulties in school and recent brush with the police were related to her lack of consistency. “He knows that I will just give in if he just bugs me long enough,” she said. Using behavioral tracking forms and developing a written list of consequences with her son helped Monique “stick to” the consequences she developed for specific behaviors. Social networks Facilitators also assist mothers in identifying members of their social networks who can help them monitor youths’ behavior and whereabouts, and provide positive and negative consequences to youth. For mothers who are raising children alone and dealing with chronic health issues, the instrumental and emotional support of other adults is crucial. Engaging other adults in this endeavor, however, often means first dealing with complicated relationships with family members, such as their own mothers, sisters, and children’s fathers. Facilitators role-play with mothers the use of positive communication tools to pinpoint specific ways family members can support their parenting efforts. Final session, “graduation” In the final session, participants review skills and techniques learned and celebrate program completion. Mothers then develop an action plan for future challenges. Finally, mothers create their own role model videotape about the progress they have made. This videotape is a tangible reminder of the mother’s achievements, reinforces her long-term action plan, and is a powerful therapeutic termination tool. Lessons learned and limitations We used a multifaceted strategy to attain the high retention rate, expending considerable energy providing reminders and resolving barriers to participation. While some community organizations may lack the capacity to undertake such an effort, our findings are encouraging as they demonstrate that high rates of retention are possible with this very vulnerable population. Mothers’ complex patterns of alcohol and drug use created challenges for intervention. Because alcohol is legal, it is not as stigmatized as other drugs. Among those who used alcohol exclusively, goal setting was often a major intervention challenge as many did not acknowledge that their drinking was problematic. By maintaining a non-judgmental stance, Springer

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accepting resistance, emphasizing a harm reduction approach, and continuing to explore alcohol-related behaviors and consequences, the program allowed participants to examine the consequences of alcohol use more objectively over time. Among those who used both alcohol and drugs, mothers found it easier to identify the adverse effects of drugs rather than alcohol. By helping mothers prioritize the substance that was causing them and their families the most harm, mothers were able to set goals that fit their most urgent concerns and their longer term goals. While harm reduction strategies such as needle exchange have become widely accepted among many injection drug users (Springer, 1996), individuals who do not inject substances may be less familiar with these principles. For those with alcohol use problems in particular, abstention is often considered the only option for treatment, consistent with the pervasiveness of 12-step programs. Many mothers were reluctant to reveal substance-related harm because they expected that the facilitators would tell them to stop using altogether. Mothers required on-going education about the utility of harm reduction and the range of options for reducing harm. The family configurations and living arrangements among Family First participants were complex and changed often. When the mother and adolescent were not living together and did not see each other consistently, facilitators needed to be highly creative. Our experience suggests that interventions need to prepare for, and adjust to, changing family patterns. The curriculum was quite appropriate for mothers with younger and middle adolescents (ages 11–16) but was more challenging to deliver to mothers whose children were 17 or 18. While Part II modified the communication skills mothers learned in Part I for use with adolescents, facilitators found that they could “go back” to the skills learned in Part I to help mothers improve communication with their older adolescents. Strategies specifically linked to age and developmental level of the target adolescents may facilitate future intervention implementation and positive outcomes. In the initial parenting sessions, several mothers indicated that the strategies outlined in the curriculum were not appropriate for non-white parents. Resistance by mothers’ social network members toward several of the parenting strategies was also noted. By the end of the 14 sessions, and in follow-up qualitative interviews (de Guzman et al., 2006) most mothers remarked on how valuable the strategies had been for increasing communication with their children and many said these strategies had become routine in their families. However, future research is warranted on how best to conceptualize effective parenting strategies in ways that are acceptable across racial and ethnic groups. The identification and enlistment of supportive members of mothers’ social networks presented a number of challenges. For example, many families lived in overcrowded apartments with other related and non-related adults who often maintained disciplinary and care-taking responsibilities for children. While these other adults filled a vacuum when mothers were using substances or feeling ill, the renegotiation of these relationships emerged as a vital aspect of the intervention. Other mothers were extremely socially isolated, used substances by themselves, and did not disclose their use to others. We also encountered a third group of mothers whose substance use typically occurred in social settings but these women had few, if any, individuals in their social network who were willing or able to assist them in their harm reduction goals. In each of these situations, facilitators assisted mothers in conducting a careful analysis of their social networks and worked on identifying and engaging existing and new members who could assist them with their goals. Mothers were often dealing with co-morbid mental health problems and experienced multiple crises throughout delivery of the intervention. The use of clinically-trained facilitators was helpful in this regard as it allowed them to individualize the curriculum, for example, Springer

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ascertaining if the crisis serves as a trigger for use and using coping strategies to deal with the crises-related stress.

Conclusions Family First is an intensive behavioral intervention program for a population at elevated risk for adverse outcomes: mothers, both HIV-infected and HIV-uninfected, with problem drinking and other drug use. Effective intervention efforts with this population have great potential public health utility. A focus on both maternal substance abuse and parent training is likely to produce positive behavioral changes in family functioning and reduce adolescent risk behaviors. Effective treatment for women requires a recognition that substance abuse is embedded in their primary interpersonal relationships. Increasing motivation for behavior change among mothers who are not actively seeking substance abuse treatment can be achieved by tapping into mothers’ desire to improve their relationship with their children, assisting them in recognizing the individual and familial consequences of their substance use, using a harm reduction approach, helping them use members of their social networks effectively, and providing intensive outreach. By attending to these factors, we achieved high rates of attendance to a multi-session intervention for a difficult to reach population.

Acknowledgments We would like to express our appreciation to the women who participated in the study; project staff members Katherine Aracena, Natalie Brumblay, Tri Cisek, Mindy Finkelstein, Karla Gostnell, Carol Moorer, Maria Elena Ramos, Amanda Ritchie, Lauren Rotko, Alberta Springer, and Maya Tharaken; the Center for Drug Use and HIV Research, Sherry Deren, Ph.D., Robert Freeman, Ph.D., and Kendall Bryant, Ph.D. for their assistance; and Jennifer K. Brown for editorial assistance. This study was supported by a grant from the National Institute on Alcohol Abuse and Alcoholism (R01-12113) to the second author.

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