Family Functioning in Hispanic Parents of Adolescents: Who Benefits Most from a Family-Based HIV and Substance Use Preventive Intervention?

To understand which families are likely to benefit most from resource-intensive family-based, evidence-based interventions (EBIs), we must examine the key, modifiable determinant of family functioning. The purpose of this study was to (1) identify whether there are subgroups of Hispanic parents that differ meaningfully based on their family functioning at baseline, (2) test whether the Familias Unidas preventive intervention was differentially effective across the baseline family functioning subgroups, and (3) understand the mechanisms of intervention effectiveness within each baseline family functioning subgroup. On a pooled data set of 4 completed efficacy and effectiveness trials of Familias Unidas (n = 1445 low-income, Hispanic immigrant origin, parents and their adolescent between the ages of 12-17), we conducted a series of secondary data analyses. Latent profile analyses revealed four significantly different profiles: (1) low family functioning (n = 210, 14.55%), (2) low-to-moderate family functioning (n = 554, 38.39%), (3) moderate-to-high family functioning (n = 490, 33.96%), and (4) high family functioning (n = 189, 13.10%). A structural equation modeling approach found there were significant differences in intervention effectiveness between the subgroups. The low family functioning subgroup experienced gains in family functioning, and in turn, lower levels of adolescent substance use, internalizing, and externalizing symptoms. The high family functioning subgroup showed significant direct effects of the intervention on adolescent substance use, internalizing, and externalizing symptoms, but no indirect effects through improvements in family functioning. Implications for screening, targeting, and adapting interventions are discussed.

A Feasibility Trial of an Online-Only, Family-Centered Preventive Intervention for Hispanics: e-Familias Unidas.

We piloted the preventive intervention e-Familias Unidas, delivered exclusively through the Internet to maximize reach and sustainability. This program is an adaptation of an evidence-based, family-centered intervention that aims to prevent Hispanic adolescent drug use and risky sexual behavior through improving family functioning. The purpose of this feasibility trial was to: (1) explore the use of Facebook and a trusted community champion in the online recruitment of Hispanic parents of adolescents, (2) test an online-only assessment and randomization protocol, (3) pilot intervention delivery via e-familiasunidas.com, and (4) assess pre-post changes in family functioning. We tracked participant recruitment and enrollment via Facebook analytics and REDCap. Intervention completion was tracked via our website. We conducted an ANCOVA to test for between group (e-Familias Unidas vs. control) differences post-intervention. Recruitment lasted for a total of 10 weeks and was divided into three phases, with each phase systematically assessing which strategies maximized recruitment and enrollment. Overall, 93 Hispanic parents enrolled in the study. Of those randomized to the intervention group (n = 46), 70% were engaged and watched an average of 5.4 out of the 12 online videos. We found that participants recruited through a community champion, versus Facebook advertisements, had higher rates of enrollment and intervention completion. There was a significant improvement in parent-adolescent communication for parents who received e-Familias Unidas compared to those in the control group (n = 47). This pilot trial demonstrated it is feasible to recruit, assess, and deliver e-Familias Unidas to Hispanic parents through an online-only platform. Our findings highlight the promise of an online platform to optimize the reach of preventive interventions for underserved populations, to more effectively target participants, and to disseminate sustainable evidence-based interventions. We discuss lessons learned and recommendations for future research.

Evidence-based prevention programs targeting youth mental and behavioral health in primary care: A systematic review.

The objectives of this systematic review were to: 1) identify evidence-based youth (i.e., infancy, pre-school age, school age, and adolescence) mental and behavioral health disorder preventive interventions conducted in or offered by primary care settings, and 2) describe these interventions' characteristics, efficacy, and clinical involvement. Randomized controlled trials that targeted the prevention of mental or behavioral health outcomes for youth and had a connection to primary care were included. The PRISMA guidelines were utilized for two phases: 1) searching PubMed, EMBASE, PsycInfo, CINAHL, and Cochrane databases in January 2017; and 2) searching United States Preventive Services Task Force (USPSTF) Systematic Reviews in November 2017. The two phases revealed 504 and 58 potential articles, respectively. After removal of duplicates, screening of abstracts, and full-text reviews, 19 interventions (infancy: n = 2, pre-school age: n = 3, school age: n = 6, adolescence: n = 8) were included: 1) 10 interventions described in 17 articles from the databases, and 2) 9 interventions described in 11 articles from the USPSTF reviews. The included interventions capitalized on primary care settings as a natural entry point to engage youth and families into interventions without requiring a large amount of clinic involvement. Commonalities of efficacious interventions and recommendations for future research are discussed. The authors encourage primary care providers, mental and behavioral health providers, and/or public health researchers to continue developing and testing preventive interventions, or adapting existing interventions, to be implemented in primary care.

Psychometric properties of an abbreviated Childhood Family Mealtime Questionnaire among overweight and obese Hispanic adolescents.

The current family mealtime literature shows that assessments of the mealtime environment are typically self-report, yet few studies discuss validation techniques or report using validated scales. As such, the current analysis was conducted to validate one of the only published measures to assess the mealtime environment from the adolescent perspective. Specifically, the Childhood Family Mealtime Questionnaire (CFMQ) was evaluated in a sample of 280 overweight and obese Hispanic adolescents to address the need for a validated measure of the family mealtime environment in a demographic that is disproportionately affected by the current obesity epidemic. Results of exploratory and confirmatory factor analyses to evaluate the optimal factor structure, reliability, and validity for a revised, abbreviated CFMQ are presented here. The concurrent validity of the CFMQ was evaluated using correlations between the factor structures and the previously used, culturally appropriate comparable measure of family functioning. Correlations were also computed between factor scores and obesogenic outcomes (fruit and vegetable intake, added sugar intake, and physical activity). Analyses produced a revised, abbreviated version that includes 22 items (reduced from a total of 69 items) and consists of the following 4 factors: family mealtime communication (5 items), family mealtime stress (7 items), appearance weight control (5 items), and mealtime structure (6 items). Cronbach's alphas are reported for reliability. When examining CFMQ concurrent validity with the family functioning latent variable, results showed the family mealtime communication subscale ranked highest. Additionally, the family mealtime communication subscale was associated with all three obesogenic outcomes. This abbreviated CFMQ may be a useful tool for those studying family mealtime environments and their influence on obesity and its associated lifestyle behaviors.

Mind the Gap: Bridging the Divide Between Current Binge Drinking Prevention and the Needs of Hispanic Underage Emerging Adults.

In this article, we highlight the urgent public health need for prevention of heavy episodic drinking among underage Hispanic emerging adults in the USA. We outline the current state of binge drinking prevention programming and contrast it with the unique cultural, social, and developmental realities of this population using an ecodevelopmental framework (Szapocznik and Coatsworth 1999). Finally, we advance specific recommendations for the development and delivery of culturally tailored, multisystemic binge drinking prevention programs for underage Hispanic emerging adults.

eHealth Familias Unidas: Efficacy Trial of an Evidence-Based Intervention Adapted for Use on the Internet with Hispanic Families.

While substance use and sexual risk behaviors among Hispanic youth continue to be public health concerns, few evidence-based preventive interventions are developed for and implemented with Hispanic/Latino youth. The objective of this study was to evaluate the efficacy of eHealth Familias Unidas, an Internet adaptation of an evidence-based family intervention for Hispanics. A randomized controlled trial design (n = 230) was used to evaluate intervention effects on substance use and condomless sex among a sample of Hispanic eighth graders with behavioral problems. Participants were randomized to eHealth Familias Unidas (n = 113) or prevention as usual (n = 117) and assessed at baseline and 3 and 12 months post baseline. We trained mental health school personnel and community mental health professionals to recruit and deliver the Internet-based intervention with Hispanic families. It was hypothesized that, over time, eHealth Familias Unidas would be more efficacious than prevention as usual in reducing drug use (marijuana, cocaine, inhalants, and other drugs), prescription drug use, cigarette use, alcohol use, and condomless sex and that these changes would be mediated by family functioning. Significant intervention effects were found across time for drug use, prescription drug use, and cigarette use. While eHealth Familias Unidas positively affected family functioning, mediation effects were not found. This study demonstrated that family-based eHealth interventions can be efficacious among Hispanic populations when delivered in community settings.

Programs for Preventing Depression in Adolescence: Who Benefits and Who Does Not? An Introduction to the Supplemental Issue.

We introduce this supplemental issue of Prevention Science, which brings together a set of papers from leading investigators who have conducted trials testing whether intervention programs prevent adolescent depression. Using data from these trials, these papers explore a series of factors that might account for variation in intervention benefit, employing several novel methods for assessing effect heterogeneity. These studies follow two general paradigms: three papers report findings from single randomized preventive intervention trials, while the remaining papers develop and apply new methods for combining data from multiple studies to evaluate effect heterogeneity more broadly. Colleagues from NIMH and SAMHSA also provide commentaries on these studies. They conclude that synthesis of findings from multiple trials holds great promise for advancing the field, and progress will be accelerated if collaborative data sharing becomes the norm rather than the exception.

Preventing Youth Internalizing Symptoms Through the Familias Unidas Intervention: Examining Variation in Response.

Prevention programs that strengthen parenting and family functioning have been found to reduce poor behavioral outcomes in adolescents, including substance use, HIV risk, externalizing and internalizing problems. However, there is evidence that not all youth benefit similarly from these programs. Familias Unidas is a family-focused intervention designed to prevent substance use and sexual risk among Hispanic youth and has recently demonstrated unanticipated reductions in internalizing symptoms for some youth. This paper examines variation in intervention response for internalizing symptoms using individual-level data pooled across four distinct Familias Unidas trials: (1) 266 eighth grade students recruited from the general school population; (2) 160 ninth grade students from the general school population; (3) 213 adolescents with conduct, aggression, and/or attention problems; and (4) 242 adolescents with a delinquency history. Causal inference growth mixture modeling suggests a three-class model. The two largest classes represent youth with low (60 %) and medium (27 %) internalizing symptoms at baseline, and both intervention and control participants show reductions in internalizing symptoms. The third class (13 %) represents youth with high levels of baseline internalizing symptoms who remain at steady levels of internalizing symptoms when exposed to the intervention, but who experience an increase in symptoms under the control condition. Female gender, low baseline levels of parent-adolescent communication, and older age were associated with membership in the high-risk class. These synthesis analyses involving a large sample of youth with varying initial risk levels represent a further step toward strengthening our knowledge of preventive intervention response and improving preventive interventions.

Predictors of Participation in an eHealth, Family-Based Preventive Intervention for Hispanic Youth.

The Familias Unidas intervention is an efficacious family-based preventive intervention for reducing substance use and other health risks among Hispanic youth. A current randomized controlled trial (RCT) is examining this intervention's efficacy when delivered via the Internet (eHealth). eHealth interventions can overcome logistical barriers to participation, yet there is limited information about the feasibility of these interventions, especially among ethnic minorities. This paper examines participation and predictors of participation in the eHealth Familias Unidas intervention in a sample of 113 Hispanic families whose adolescent had behavioral problems. Analyses examined multidimensional ways of characterizing participation, including the following: (1) total intervention participation, (2) initial engagement (participating in at least one of the first three intervention sessions), (3) completing the pre-recorded, eHealth parent group sessions, and (4) participating in the live, facilitator-led, eHealth family sessions. Participation in this eHealth intervention was comparable to, and in most cases higher than, previous, face-to-face Familias Unidas interventions. High levels of baseline family stress were associated with lower initial engagement and lower family session participation. Greater parental Hispanicism was associated with more participation in eHealth parent group sessions and across the total intervention. Higher levels of baseline effective parenting, in other words less intervention need, were significantly associated with lower levels of total intervention participation and lower levels of family session participation. Implications for preventive interventions delivered via Internet are discussed.

Addressing Methodologic Challenges and Minimizing Threats to Validity in Synthesizing Findings from Individual-Level Data Across Longitudinal Randomized Trials.

Integrative Data Analysis (IDA) encompasses a collection of methods for data synthesis that pools participant-level data across multiple studies. Compared with single-study analyses, IDA provides larger sample sizes, better representation of participant characteristics, and often increased statistical power. Many of the methods currently available for IDA have focused on examining developmental changes using longitudinal observational studies employing different measures across time and study. However, IDA can also be useful in synthesizing across multiple randomized clinical trials to improve our understanding of the comprehensive effectiveness of interventions, as well as mediators and moderators of those effects. The pooling of data from randomized clinical trials presents a number of methodological challenges, and we discuss ways to examine potential threats to internal and external validity. Using as an illustration a synthesis of 19 randomized clinical trials on the prevention of adolescent depression, we articulate IDA methods that can be used to minimize threats to internal validity, including (1) heterogeneity in the outcome measures across trials, (2) heterogeneity in the follow-up assessments across trials, (3) heterogeneity in the sample characteristics across trials, (4) heterogeneity in the comparison conditions across trials, and (5) heterogeneity in the impact trajectories. We also demonstrate a technique for minimizing threats to external validity in synthesis analysis that may result from non-availability of some trial datasets. The proposed methods rely heavily on latent variable modeling extensions of the latent growth curve model, as well as missing data procedures. The goal is to provide strategies for researchers considering IDA.

Two-Year Impact of Prevention Programs on Adolescent Depression: an Integrative Data Analysis Approach.

This paper presents the first findings of an integrative data analysis of individual-level data from 19 adolescent depression prevention trials (n = 5210) involving nine distinct interventions across 2 years post-randomization. In separate papers, several interventions have been found to decrease the risk of depressive disorders or elevated depressive/internalizing symptoms among youth. One type of intervention specifically targets youth without a depressive disorder who are at risk due to elevated depressive symptoms and/or having a parent with a depressive disorder. A second type of intervention targets two broad domains: prevention of problem behaviors, which we define as drug use/abuse, sexual risk behaviors, conduct disorder, or other externalizing problems, and general mental health. Most of these latter interventions improve parenting or family factors. We examined the shared and unique effects of these interventions by level of baseline youth depressive symptoms, sociodemographic characteristics of the youth (age, sex, parent education, and family income), type of intervention, and mode of intervention delivery to the youth, parent(s), or both. We harmonized eight different measures of depression utilized across these trials and used growth models to evaluate intervention impact over 2 years. We found a significant overall effect of these interventions on reducing depressive symptoms over 2 years and a stronger impact among those interventions that targeted depression specifically rather than problem behaviors or general mental health, especially when baseline symptoms were high. Implications for improving population-level impact are discussed.

Familias Unidas for Health and Wellness: Adapting an Evidence-Based Substance Use and Sexual Risk Behavior Intervention for Obesity Prevention in Hispanic Adolescents.

We describe the adaptation of Familias Unidas, an evidence-based substance use and sexual risk behavior intervention, for obesity prevention in Hispanic adolescents. Intervention developers and experts in pediatric obesity, exercise physiology, dietetics, and the local parks system provided input for changes. Hispanic families also provided input through a series of 21 focus groups conducted before, during, and after an initial pilot test of the adapted intervention. After transcribing audiotaped sessions, we used a general inductive approach and Dedoose qualitative software to derive themes. Results indicated the need for improved health-related family functioning, enhanced nutrition education and skill building, increased family engagement in physical activity, and stronger links between family and environmental supports. Parents who participated in the pilot test expressed high enthusiasm for hands-on nutrition training and reported improvements in family functioning. Adolescents liked outdoor physical activities but wanted parents to be more engaged in joint physical activity sessions. The adapted intervention maintains fidelity to Familias Unidas' core theoretical elements and overall structure, but also includes content focused on physical activity and nutrition, adolescent participation in physical activity sessions led by park coaches, and joint parent-adolescent participation in physical activity and nutrition skill-building activities.

Parent-Centered Prevention of Risky Behaviors Among Hispanic Youths in Florida.

OBJECTIVES: To evaluate the effectiveness of an evidence-based, parent-centered intervention, Familias Unidas, delivered by nonresearch personnel, in preventing substance use (alcohol, illicit drugs) and sex without a condom among Hispanic adolescents. METHODS: A randomized controlled trial (n = 746) evaluated the effectiveness of Familias Unidas among Hispanic eighth graders (age range = 12-16 years), relative to prevention as usual, within a public school system. School personnel, including social workers and mental health counselors, were trained to deliver the evidence-based intervention. Participant recruitment, intervention delivery, and follow-up ran from September 2010 through June 2014 in Miami-Dade County, Florida. RESULTS: Familias Unidas was effective in preventing drug use from increasing and prevented greater increases in sex without a condom 30 months after baseline, relative to prevention as usual. Familias Unidas also had a positive impact on family functioning and parental monitoring of peers at 6 months after baseline. CONCLUSIONS: This study demonstrated the effectiveness of a parent-centered preventive intervention program in preventing risky behaviors among Hispanic youths. Findings highlight the feasibility of training nonresearch personnel on effectively delivering a manualized intervention in a real-world setting.

Short-Term Effects on Family Communication and Adolescent Conduct Problems: Familias Unidas in Ecuador.

Familias Unidas, a Hispanic/Latino-specific, parent-centered intervention, found to be efficacious in improving family functioning and reducing externalizing behaviors among youth in the USA, was recently adapted and tested for use in Ecuador. This study examined the short-term efficacy of Familias Unidas in Ecuador on parent-adolescent communication, parental monitoring of peers, and youth conduct problems. Two hundred thirty-nine youths (ages 12-14 years) and their primary care givers were randomized to either Familias Unidas or Community Practice and assessed pre- and post-intervention. There was a significant difference between Familias Unidas and Community Practice in conduct problems at 3 months (standardized ß = -.101, p = .001, effect size = .262). A significant indirect intervention effect was also detected, indicating that Familias Unidas predicted conduct problems at 3 months through parent-adolescent communication at 3 months (standardized ß = -.036, p = .016, CI 95% [-.066, -.007], effect size = .265). Familias Unidas was efficacious in reducing conduct problems through improved parent-adolescent communication, relative to Community Practice. Future assessments will determine whether Familias Unidas also has an impact on substance use and sexual risk behaviors at later time points, as demonstrated in past Familias Unidas trials. The short-term effects of the intervention, family engagement, and facilitator skill in the Ecuadorian adaptation of Familias Unidas are promising. This study implies that an intervention developed for Hispanics/Latinos in the USA and culturally adapted and implemented for use by Hispanics/Latinos in a Latin American country can be efficacious in improving family functioning and reducing youth conduct problems. TRIAL REGISTRATION: MSP-DIS-2015-0055-0, Ministry of Public Health (MSP), Ecuador.

Engaging School Mental Health Professionals to Deliver Evidence-Based Interventions to Hispanic Families.

Research has demonstrated that a number of evidence-based programs can be effectively implemented in different community settings, such as schools, to target Hispanic youth and their families; however, successful implementation of such programs represents a challenge for practitioners. This article describes experiences and strategies associated with recruiting, training, and supervising school mental health professionals in the school-based implementation of an evidence-based, family-centered prevention program for Hispanic families. School mental health professionals were recruited and given intensive training, weekly supervision for adherence monitoring, and ongoing technical assistance, in addition to intervention manuals and materials. We emphasize how strategies based on the prevention program itself were used to recruit, engage, and train school mental health professionals to deliver a family-based evidence-based program, blending research and practice in a large public school system. Implications of lessons learned are discussed, as well as the specific strategies to overcome challenges when engaging and training community partners in delivering a manualized intervention with rigorous adherence to the program.

Reducing Internalizing Symptoms Among High-Risk, Hispanic Adolescents: Mediators of a Preventive Family Intervention.

Familias Unidas is a family-focused preventive intervention that has been found to reduce drug use and sexual risk behaviors among Hispanic adolescents. In some trials, Familias Unidas has also been found to be efficacious in reducing adolescent internalizing symptoms (i.e., depressive and anxiety symptoms), even though the intervention did not specifically target internalizing symptoms. This study examines potential mediators or mechanisms by which Familias Unidas influences internalizing symptoms, specifically the role of intervention-targeted improvements in parent-adolescent communication and reductions in youth externalizing behaviors. A total of 213 Hispanic eighth grade students with a history of externalizing behavior problems and their primary caregivers were recruited from the public school system. Participants, with a mean age of 13.8 years, were randomized into the Familias Unidas intervention or community practice control condition and assessed at baseline, 6, 18, and 30 months post-baseline. A cascading mediation model was tested in which the Familias Unidas intervention was hypothesized to decrease adolescent internalizing symptoms through two mediators: improvements in parent-adolescent communication leading to decreases in externalizing behaviors. Findings show that the intervention had significant direct effects on youth internalizing symptoms at 30 months post-baseline. In addition, the cascading mediation model was supported in which the Familias Unidas intervention predicted significant improvements in parent-adolescent communication at 6 months, subsequently decreasing externalizing behaviors at 18 months, and ultimately reducing youth internalizing symptoms at 30 months post-baseline. Implications for prevention interventions are discussed.

Reducing the Risk of Internalizing Symptoms among High-risk Hispanic Youth through a Family Intervention: A Randomized Controlled Trial.

Familias Unidas is an intervention that has been found to be efficacious in preventing and reducing substance use, sexual risk, and problem behaviors among Hispanic youth. While it does not specifically target youth internalizing symptoms, the intervention works to strengthen parenting and family factors associated with reduced risk of internalizing symptoms (i.e., depression, anxiety symptoms). This study examines the effects of Familias Unidas on internalizing symptoms among high-risk youth, as well as the role of family level factors in the intervention's effects. A total of 242 12-17-year-old Hispanic youth with a history of delinquency and their primary caregivers were recruited from the school and juvenile justice systems, and randomly assigned to the Familias Unidas intervention or community practice control. A linear latent growth model was used to examine intervention effects on the trajectory of adolescent internalizing symptoms from baseline to 6 and 12 months post-baseline. Results show that the Familias Unidas intervention was more efficacious than control in reducing youth internalizing symptoms. Baseline youth externalizing and internalizing symptoms did not moderate the intervention's effects on the trajectory of youth internalizing symptoms. While parent-adolescent communication did not significantly moderate the intervention's effects, changes in parent-adolescent communication mediated the intervention's effects on internalizing symptoms, showing stronger intervention effects for youth starting with poorer communication. Findings indicate that the Familias Unidas intervention can reduce internalizing symptoms among high-risk Hispanic youth, and that improving parent-youth communication, a protective family factor, may be one of the mechanisms by which the intervention influences youth internalizing symptoms.

Toward scientific equity for the prevention of depression and depressive symptoms in vulnerable youth.

Certain subgroups of youth are at high risk for depression and elevated depressive symptoms, and experience limited access to quality mental health care. Examples are socioeconomically disadvantaged, racial/ethnic minority, and sexual minority youth. Research shows that there are efficacious interventions to prevent youth depression and depressive symptoms. These preventive interventions have the potential to play a key role in addressing these mental health disparities by reducing youth risk factors and enhancing protective factors. However, there are comparatively few preventive interventions directed specifically to these vulnerable subgroups, and sample sizes of diverse subgroups in general prevention trials are often too low to assess whether preventive interventions work equally well for vulnerable youth compared to other youth. In this paper, we describe the importance and need for "scientific equity," or equality and fairness in the amount of scientific knowledge produced to understand the potential solutions to such health disparities. We highlight possible strategies for promoting scientific equity, including the following: increasing the number of prevention research participants from vulnerable subgroups, conducting more data synthesis analyses and implementation science research, disseminating preventive interventions that are efficacious for vulnerable youth, and increasing the diversity of the prevention science research workforce. These strategies can increase the availability of research evidence to determine the degree to which preventive interventions can help address mental health disparities. Although this paper utilizes the prevention of youth depression as an illustrative case example, the concepts are applicable to other health outcomes for which there are disparities, such as substance use and obesity.

Blending Qualitative and Computational Linguistics Methods for Fidelity Assessment: Experience with the Familias Unidas Preventive Intervention.

Careful fidelity monitoring and feedback are critical to implementing effective interventions. A wide range of procedures exist to assess fidelity; most are derived from observational assessments (Schoenwald and Garland, Psycholog Assess 25:146-156, 2013). However, these fidelity measures are resource intensive for research teams in efficacy/effectiveness trials, and are often unattainable or unmanageable for the host organization to rate when the program is implemented on a large scale. We present a first step towards automated processing of linguistic patterns in fidelity monitoring of a behavioral intervention using an innovative mixed methods approach to fidelity assessment that uses rule-based, computational linguistics to overcome major resource burdens. Data come from an effectiveness trial of the Familias Unidas intervention, an evidence-based, family-centered preventive intervention found to be efficacious in reducing conduct problems, substance use and HIV sexual risk behaviors among Hispanic youth. This computational approach focuses on "joining," which measures the quality of the working alliance of the facilitator with the family. Quantitative assessments of reliability are provided. Kappa scores between a human rater and a machine rater for the new method for measuring joining reached 0.83. Early findings suggest that this approach can reduce the high cost of fidelity measurement and the time delay between fidelity assessment and feedback to facilitators; it also has the potential for improving the quality of intervention fidelity ratings.

Preventing internalizing symptoms among Hispanic adolescents: a synthesis across Familias Unidas trials.

Studies document that there are efficacious interventions to prevent adolescent depression and internalizing symptoms, including several family-focused interventions. Questions remain about for whom interventions work (moderation) and by what mechanisms they work (mediation) to prevent internalizing symptoms. Unfortunately, single trials are often underpowered to address moderation and mediation, an issue addressed in this paper. This synthesis study combined individual-level, longitudinal data from 721 adolescents across 3 randomized clinical trials of Familias Unidas, a family-focused prevention intervention for Hispanic youth. Using integrative data analysis (IDA) methods applied to trials, the study examined intervention moderation and mediation effects on internalizing symptoms. Baseline internalizing symptoms were a significant moderator of the intervention's effects on internalizing symptoms, while baseline externalizing symptoms did not moderate intervention effects. Baseline parent-adolescent communication, a modifiable risk factor and hypothesized mechanism by which the intervention works, significantly moderated the intervention's effects. Specifically, the intervention was more efficacious in its impact on internalizing symptoms for youth with lower initial levels of parent-adolescent communication compared to those with higher communication levels. Moderated mediation analyses showed that parent-adolescent communication changes mediated the intervention's effects on internalizing symptoms, with stronger effects for those with poorer baseline communication. Results suggest a potential benefit of identifying youth risks prior to interventions, and targeting specific modifiable mediators that lead to reductions of internalizing problems of adolescents. Findings also highlight advantages of utilizing data from combined trials and IDA for examining intervention moderators and mediators.