Walton MA, Chermack ST, Shope JT, Bingham CR, Zimmerman MA, Blow FC, Cunningham RM. Effects of a Brief Intervention for Reducing Violence and Alcohol Misuse Among AdolescentsA Randomized Controlled Trial. JAMA. 2010;304(5):527-535. doi:10.1001/jama.2010.1066
Author Affiliations: Department of Psychiatry (Drs Walton, Chermack, and Blow), School of Public Health (Drs Shope, Bingham, Zimmerman, and Cunningham), Transportation Research Institute (Drs Shope and Bingham), and Injury Prevention Center, Department of Emergency Medicine (Dr Cunningham), University of Michigan, and Health Services Research and Development, Department of Veterans Affairs (Drs Chermack and Blow), Ann Arbor; and Hurley Medical Center, Flint, Michigan (Dr Cunningham).
Context Emergency department (ED) visits present an opportunity to deliver brief interventions to reduce violence and alcohol misuse among urban adolescents at risk of future injury.
Objective To determine the efficacy of brief interventions addressing violence and alcohol use among adolescents presenting to an urban ED.
Design, Setting, and Participants Between September 2006 and September 2009, 3338 patients aged 14 to 18 years presenting to a level I ED in Flint, Michigan, between 12 PM and 11 PM 7 days a week completed a computerized survey (43.5% male; 55.9% African American). Adolescents reporting past-year alcohol use and aggression were enrolled in a randomized controlled trial (SafERteens).
Intervention All patients underwent a computerized baseline assessment and were randomized to a control group that received a brochure (n = 235) or a 35-minute brief intervention delivered by either a computer (n = 237) or therapist (n = 254) in the ED, with follow-up assessments at 3 and 6 months. Combining motivational interviewing with skills training, the brief intervention for violence and alcohol included review of goals, tailored feedback, decisional balance exercise, role plays, and referrals.
Main Outcome Measures Self-report measures included peer aggression and violence, violence consequences, alcohol use, binge drinking, and alcohol consequences.
Results About 25% (n = 829) of screened patients had positive results for both alcohol and violence; 726 were randomized. Compared with controls, participants in the therapist intervention showed self-reported reductions in the occurrence of peer aggression (therapist, −34.3%; control, −16.4%; relative risk [RR], 0.74; 95% confidence interval [CI], 0.61-0.90), experience of peer violence (therapist, −10.4%; control, +4.7%; RR, 0.70; 95% CI, 0.52-0.95), and violence consequences (therapist, −30.4%; control, −13.0%; RR, 0.76; 95% CI, 0.64-0.90) at 3 months. At 6 months, participants in the therapist intervention showed self-reported reductions in alcohol consequences (therapist, −32.2%; control, −17.7%; odds ratio, 0.56; 95% CI, 0.34-0.91) compared with controls; participants in the computer intervention also showed self-reported reductions in alcohol consequences (computer, −29.1%; control, −17.7%; odds ratio, 0.57; 95% CI, 0.34-0.95).
Conclusion Among adolescents identified in the ED with self-reported alcohol use and aggression, a brief intervention resulted in a decrease in the prevalence of self-reported aggression and alcohol consequences.
Trial Registration clinicaltrials.gov Identifier: NCT00251212
In the United States in 2006, there were 19 525 000 emergency department (ED) visits by patients aged 15 to 24 years.1 The ED is an important contact point for medical care for adolescents, especially underinsured and uninsured patients.2,3 Prevention programs in the ED may reach adolescents who do not attend school regularly, who lack a primary care physician, or who view themselves as too old to be seen by pediatricians and have not established adult medical care.
Adolescents seeking care in the ED are an important population for injury prevention based on increased risk of problems related to alcohol and violence.4,5 Despite a recent increase in ED-based interventions for youth violence6- 9 or alcohol use,10- 13 few ED studies have examined brief interventions that address reductions in violence or the combination of co-occurring risk behaviors (eg, violence and alcohol).14 These approaches could substantially affect public health, especially if designed to be easily incorporated into ED practice. Computerized brief interventions are mostly untested in the ED and offer a practical solution to barriers in this setting.
This article examines 3- and 6-month outcomes from a randomized controlled trial (RCT) (SafERteens) of a therapist brief intervention (assisted by computer) or a computer brief intervention vs a control condition among adolescents aged 14 to 18 years presenting to an urban ED who screened positive for violence and alcohol use. Hypotheses were that the therapist and computer interventions would be more effective than the control in reducing violence and alcohol misuse at 3 and 6 months' follow-up.
The SafERteens RCT took place at Hurley Medical Center in Flint, Michigan, a level I trauma center. Study procedures were approved by the University of Michigan and Hurley Medical Center institutional review boards; a National Institutes of Health Certificate of Confidentiality for human subjects was obtained.
Emergency department patients aged 14 to 18 years who presented for medical illness or injury were eligible for screening. Exclusions were acute sexual assault or suicidal ideation, altered mental status precluding consent, or medical instability (ie, abnormal vital signs).
Recruitment occurred between 12 PM and 11 PM 7 days a week (September 2006–September 2009), excluding major holidays. Adolescent patients identified from electronic logs were approached by research assistants in waiting rooms or treatment spaces. Following obtainment of written consent (and assent and parent/guardian consent if <18 years), participants self-administered a 15-minute computerized survey with audio and received a $1.00 gift.
After completing the survey, participants reporting both past-year aggression (peer, dating, weapon carriage/use) and alcohol consumption (“In the past 12 months, have you had a drink of beer, wine or liquor more than two to three times? Do not count just a sip or taste of someone else's drink.”)15 were eligible for the RCT. Participants reporting only 1 behavior (aggression or alcohol use) were not eligible.
Following obtainment of written consent (and assent and parent/guardian consent if <18 years) for the RCT, participants self-administered a computerized baseline assessment ($20 remuneration). As required by the institutional review board, participants were told they would be randomly assigned to 1 of 3 groups: computer session, counselor session, or brochure. Participants were blinded to condition assignment until after the baseline assessment. After the baseline, participants were randomized and received the therapist brief intervention, computer brief intervention, or control brochure during the ED visit. Randomization was stratified by sex and age (14-15 or 16-18 years) and assigned based on computer-generated algorithm and using numbered sealed envelopes. Randomization occurred in blocks of 21 (7 per group).
Participants self-administered computerized follow-up assessments 3 and 6 months after the ED visit at a convenient location (eg, home, ED, restaurant); remuneration was $25 and $30, respectively. Follow-up staff were blinded to baseline condition assignment.
Previously validated measures were used; piloting (n = 23) was conducted to ensure that youth could understand and self-administer the assessments and interventions.16- 18 The time frame for questions was the past year at screening/baseline and past 3 months at follow-ups.
Demographic information collected included age, sex, race, ethnicity, and receipt of public assistance.15
Alcohol use frequency, quantity (on a typical occasion), and binge drinking (≥5 drinks) were assessed with the Alcohol Use Disorders Identification Test–Consumption (AUDIT-C).19,20 As recommended for adolescents,21 binge drinking quantity was 5 drinks or more instead of 6 or more. Piloting revealed that question 1 response options were misunderstood by urban teens and were replaced with the response options for question 3. An alcohol consumption summary variable was computed (α = .81); among adolescents, the cutoff is 3 or more for an alcohol use disorder.21
The 17-item substance abuse scale from the Problem Oriented Screening Instrument for Teenagers (POSIT)22 measured alcohol consequences (eg, missed school, trouble getting along with friends because of drinking). An alcohol consequences summary variable was created (α = .83). Among adolescents, the cutoff is 2 for an alcohol use disorder.23
Ten items24,25 assessed frequency of aggression toward peers and included moderate (eg, pushed or shoved) and severe (eg, hit or punched, used a knife/gun) aggression (α = .86). Peer aggression was computed by summing the midpoint of the responses.26 Knife/razor and gun carriage frequency was assessed using 2 items. Two items assessed frequency of moderate and severe dating aggression.5,27
Experiencing moderate or severe peer violence was assessed by collapsing the moderate and severe peer aggression items into 2 questions. The score was computed by summing the midpoint of the items (α =.77).
Using a 7-item scale developed for this study, participants identified consequences of fighting (ie, trouble at school, hurt someone, constant desire to fight, family or friends suggested they stop, arguments with family or friends, trouble getting along with friends, inability to control fighting). A violence consequences summary variable was created (α =.78).
Current ED visit reason (ie, chief concern) was abstracted from the medical chart as medical illness (eg, abdominal pain, asthma) or injury (intentional [International Classification of Diseases, Ninth Revision codes E950-E969] or unintentional [codes E800-E869, E880-E929]). Chart reviews were audited regularly to maintain reliability using established criteria.28
Participants who were randomized to the brief interventions received their assigned condition prior to ED discharge in treatment spaces; interventions could be stopped and restarted as needed to avoid interference with medical care. Research staff ensured that sessions were completed privately. Participants in all groups, including the control condition, received a brochure with community resources. The SafERteens brief interventions were based on principles of motivational interviewing29,30 but also involved normative resetting and alcohol refusal and conflict resolution skills practice.31 The therapist and computer interventions were designed to have similar sections but with different modes of presentation. They were developed to be culturally relevant for urban youth, of whom at this study site approximately 50% were African American. Quiz Ref IDThe sections included goals, personalized feedback for alcohol, violence, and weapon carriage, decisional balance exercise for the potential benefit of staying away from drinking and fighting, 5 tailored role plays (eg, anger management, conflict resolution, alcohol refusals, not drinking and driving), and referral. Although both interventions reviewed these content areas in a way that was consistent with tenets of motivational interviewing (ie, nonjudgmental), the mode of delivery resulted in important differences. For example, it was not possible for the computer to provide complex interpersonal responses that a skilled therapist could deliver.
The therapist intervention was also facilitated by a tablet laptop computer that displayed tailored feedback for participants and screens to prompt content for the therapists. Research social workers were initially trained on motivational interviewing techniques and the specific SafERteens intervention. Based on harm reduction principles, which are well suited for adolescents,32,33 motivational interviewing emphasizes developing a discrepancy between current behavior and future goals and increasing problem recognition, motivation, and self-efficacy. To ensure fidelity, sessions were audiotaped and 20% were coded based on adherence and competence; therapists received individual and group supervision and periodic retrainings throughout the study.
The computer intervention developed for this study was a stand-alone interactive animated program31 with touch screens and audio via headphones to ensure privacy. An animated character guided participants through the intervention components via audio feedback for the choices made, focusing on tipping the decisional balance away from risk behaviors. The entire computer program was an interaction, not passively viewed. For example, during the role-play scenarios, participants had to interact with peers and make behavioral choices about drinking and fighting.
Data were analyzed using SAS version 9 (SAS Institute Inc; Cary, North Carolina). Descriptive statistics were computed for the total sample and by assigned condition. Because of baseline differences by condition in rates of participant school dropout, this variable was initially included in analyses to control for group differences. Models are presented without this covariate, however, because it was unrelated to outcomes when it was included in initial analyses. For descriptive purposes, rates of occurrence of risk behaviors are presented as percentages along with percentage change at 3 and 6 months. At baseline, a single imputation procedure was used to complete missing alcohol misuse scores for 5 participants. The 1-tailed statistical significance was set at P < .05 and was expressed as a 95% confidence interval.
Data were analyzed using generalized estimating equations (GEE) due to the correlated structure of data from repeated measures at baseline and 3- and 6-month follow-up.34 The GEE analyses allow for observed variable distributions (eg, binary/logit, continuous/negative binomial). An intention-to-treat approach was used in which all randomized participants (n = 726) were included because GEE analyses include all cases, even dropouts, by using available pairs to estimate working correlation parameters for the entire sample. The study was powered to detect differences between intervention groups and the control, not between treatment conditions (eg, therapist brief intervention and computer brief intervention); thus, analyses compared each intervention condition separately with the control condition. Based on 15% reduction in occurrence of a risk behavior and P < .05 significance, 107 per group was needed for 80% power; thus, the analyses were adequately powered.
Because the intervention focused on decreasing the occurrence as well as the frequency of the risk behaviors, GEE analyses were conducted examining group differences over time in the occurrence (binary variables) and frequency (continuous variables) of primary outcomes (ie, peer aggression, violence consequences, alcohol misuse [AUDIT-C score], binge drinking, and alcohol consequences) and secondary outcomes (ie, experiencing peer violence). The GEE analyses produces a model group × time interaction effect, as well as specific group × time interaction effects for the therapist and computer conditions compared with the control. For conservative purposes, only models with significant overall group × time interaction effects were examined further to determine intervention effectiveness (ie, therapist group × time interaction, computer group × time interaction). A significant therapist group × time interaction effect indicates that the intervention condition significantly differs from the control in a specific outcome; thus, this analysis approach considers baseline values and the relative change over time in outcomes based on group assignment. Because violence was a common occurrence, relative risks are reported for violence-related variables; for alcohol-related variables, odds ratios are reported because these are less common events and this allows for comparison with the published literature.
Regarding effect sizes, for outcomes using binary variables percentage change was computed. For continuous variables, Cohen effect sizes35 were calculated, which indicate the strength of the relationship between the intervention and the observed outcome and allow for comparisons across studies; the prevention literature suggests that effect sizes of 0.10 or higher are clinically meaningful.36
Among 4296 potentially eligible patients presenting during recruitment, 3784 (88.1%) were approached (Figure). At screening, no race differences were observed in refusals; male patients were more likely to refuse than female patients (male, n = 224 [13.0%]; female, n = 222 [10.7%], respectively; χ21 = 4.74; P = .03). At baseline, African Americans were less likely to refuse than other races/ethnicities (African American, n = 41 [9.2%]; other, n = 60 [15.8%]; χ21 = 8.38; P = .004) and male patients were more likely to refuse than female patients (male, n = 56 [15.1%]; female, n = 45 [9.9%]; χ21 = 5.09; P = .02). The follow-up rate exceeded 85%.
Table 1 characterizes the sample by assigned condition. Participants assigned to the computer intervention were more likely to have dropped out of school compared with the therapist intervention or control. No other significant differences were observed between groups.
Generalized estimating equation models were computed for occurrence of violence (severe peer aggression, any experience of peer violence, any violence consequences) and alcohol (alcohol misuse ≥3, any binge drinking, alcohol consequences ≥2) at 3 and 6 months (Table 2 shows descriptive data; Table 3 and Table 4 show GEE results). Participants in the therapist intervention were less likely to report any severe peer aggression at 3 months (model group × time interaction, χ22 = 11.79; P = .003), experience of peer violence at 3 months (model group × time interaction, χ22 = 6.96; P = .03), and violence consequences at 3 months (model group × time interaction, χ22= 14.50; P<.001) than controls. Models were not significant for severe peer aggression at 6 months, alcohol misuse and binge drinking at 3 and 6 months, or alcohol consequences at 3 months. Quiz Ref IDAt 6 months, the alcohol consequences model was significant (model group × time interaction, χ21 = 6.82; P = .03); participants in the therapist and computer conditions were less likely to report consequences than controls.
Generalized estimating equation models were computed for frequency of violence (peer aggression, experience of peer violence, violence consequences) and alcohol (alcohol misuse, binge drinking, alcohol consequences) at 3 months and 6 months (data not presented). The models were not significant for the frequency of peer aggression or experience of peer violence at 3 and 6 months or for the frequency of violence consequences at 6 months. The model for the number of violence consequences at 3 months was significant (model group × time interaction, χ22 = 8.56; P = .01). Participants in the therapist intervention decreased the number of violence consequences compared with controls at 3 months (therapist group × time interaction, P = .005; effect size, 0.27; odds ratio = 0.77; 95% confidence interval, 0.65-0.93). None of the models were significant for the alcohol frequency variables.
Although replication is required, our data provide novel findings demonstrating that a brief intervention for violence and alcohol among adolescents presenting to an urban ED shows promise, reducing experience of peer violence and alcohol consequences. Quiz Ref IDGiven that a leading cause of mortality and morbidity in this age group is violence, the reduction in the occurrence of severe violence following a single-session brief intervention is clinically meaningful. Specifically, only 8 at-risk adolescents (with past-year alcohol use and aggression) would need to receive the therapist intervention to prevent severe peer aggression in 1 adolescent. In addition, participants in the therapist intervention reported a reduction in the occurrence of experiencing peer violence and violence consequences at 3 months. Clinically, a trained ED-based therapist would need to deliver this 30-minute intervention to 10 at-risk adolescents to prevent 1 adolescent from being victimized by a peer. In a similar manner, the number of adolescents needed to treat with the therapist intervention is 6 to reduce violence consequences in 1 adolescent.
Quiz Ref IDThis study focused on at-risk youth seeking general ED care for a single-session intervention delivered completely during the teachable moment of the acute care visit. Prior hospital and ED interventions for youth violence have focused on patients with intentional injury and have typically used multisession case management or mentoring approaches.6,9,37 Additional studies with larger samples of adolescents who are seeking care following an intentional injury (eg, assault, gunshot) are needed to determine the effectiveness of this intervention among youth with more severe violence profiles. Few ED studies have examined alcohol brief interventions among adolescents. Adolescents in the therapist intervention and the computer intervention were less likely to report alcohol-related consequences (eg, missed school, trouble with friends) than those in the control condition over the 6-month follow-up. Clinically, to prevent alcohol consequences in 1 adolescent, 17 adolescents would need to receive the therapist intervention; alternatively, 13 adolescents would need to receive the computer intervention to prevent alcohol consequences in 1 adolescent. These mixed findings for reductions in alcohol consequences but not consumption are consistent with prior adolescent studies of a therapist brief intervention11 and computer brief intervention38 in the ED.
Data from this study did not support the effectiveness of the stand-alone computerized intervention for reducing violence. It is important to recognize, however, that a computer played a role in the therapist condition. Assessments were computerized and the adolescents and therapists reviewed tailored feedback presented on the computer. The computer screens standardized the delivery of the intervention by the therapist; such approaches are appealing as a mechanism to prompt content for busy ED staff.
A limitation of this study is that it is not possible for participants to be blinded to the intervention condition given current institutional review board requirements. This concern is somewhat mitigated by blinding of follow-up staff to intervention condition assignment as well as by the self-administered nature of assessments. Findings may not generalize to patient groups not included in this single-site study, such as adolescents presenting during overnight shifts or with acute suicidal ideation/attempt or sexual assault. Although the sample reflected the ED study site composition, replication with other sites and samples (eg, Hispanics) are needed. The self-report data are a potential limitation; however, recent reviews support the reliability and validity of self-report of risk behaviors when privacy/confidentiality is ensured and when using self-administered computerized assessments.39 Although the follow-up rates exceeded 85% and analyses included all participants regardless of dropout, attrition is a limitation of this study. Findings are limited by the 6-month follow-up. Quiz Ref IDFuture studies are needed that examine long-term follow-up, moderators of outcome such as age, and the temporal relationship between acute alcohol consumption and violence using calendar-based assessments.40
Although replication is required, findings support the efficacy of a therapist brief intervention (with computerized feedback and structure) in decreasing the occurrence of experiencing peer violence in the 3 months following an ED visit. In addition, both the therapist and the computer brief interventions were effective at reducing alcohol consequences over 6 months. Computerized approaches could assist in translating research findings into routine clinical practice by standardizing intervention delivery and have wide applicability across other content areas and settings.
Corresponding Author: Maureen A. Walton, MPH, PhD, University of Michigan, Rachel Upjohn Bldg, 4250 Plymouth Rd, Ann Arbor, MI 48109 (firstname.lastname@example.org).
Author Contributions: Drs Walton and Cunningham had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Walton, Chermack, Shope, Bingham, Zimmerman, Blow, Cunningham.
Acquisition of data: Walton, Chermack, Blow, Cunningham.
Analysis and interpretation of data: Walton, Chermack, Zimmerman, Cunningham.
Drafting of the manuscript: Walton, Chermack, Bingham, Zimmerman, Cunningham.
Critical revision of the manuscript for important intellectual content: Walton, Chermack, Shope, Zimmerman, Blow, Cunningham.
Statistical analysis: Walton, Chermack, Cunningham.
Obtained funding: Walton, Chermack, Shope, Bingham, Zimmerman, Blow, Cunningham.
Administrative, technical, or material support: Shope, Blow.
Study supervision: Walton, Chermack, Cunningham.
Financial Disclosures: None reported.
Funding/Support: This project was supported by National Institute on Alcohol Abuse and Alcoholism (NIAAA) grant 014889.
Role of the Sponsor: The NIAAA had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, or approval of the manuscript.
Additional Contributions: We thank project staff for their work, as well as Pat Bergeron (not paid by the project) for administrative assistance and Linping Duan, MS, for statistical support (paid analyst for the project), both from the University of Michigan. Finally, we thank the patients and medical staff at Hurley Medical Center for their support of this project.