Arms crossed, eyes rolled, heavy sighs. Teens’ body language often suggests utter disregard for adults’ advice. The phenomenon may peak during discussions about substance use, which is one reason some pediatricians may bypass substance abuse counseling during annual visits. Yet the American Academy of Pediatrics (AAP) recommends physicians screen all adolescents for alcohol at least once a year. New research from the Center for Adolescent Substance Abuse Research (CeASAR) at Boston Children’s Hospital may allay physicians’ fears.
A brief computer-facilitated counseling session during an annual physician visit reduced drinking among teens whose friends drink or approve of drinking. In a study of 2,092 12- to 18-year-old patients, teens with friends who drink (those with peer risk) had reduced alcohol use at three-month follow-up, Jennifer Louis-Jacques, MD, MPH, from Boston Children’s Division of Adolescent Medicine, reported in a study published online Nov. 11 in Journal of Adolescent Health.
Priming the pump
“While pediatricians want to comply with the AAP recommendation to screen adolescents, one barrier is the number of health-risk screenings that must be crammed into a 15-minute office visit,” says Sion Kim Harris, PhD, an epidemiologist and data analyst within CeASAR.
Another challenge is the (mis)perception that what adults say doesn't matter to teens.
Kids live and breathe a peer- and media-centric lifestyle. Most teens’ contact with a physician is limited to 15 minutes each year. Conventional wisdom asks, “How can a conversation with a doctor make any difference in teens’ substance use?” But it turns out that talk does matter. “Research shows that teens trust their doctors in this area," says Harris. "They view them as trustworthy sources of health information, and plan to follow their advice more often than not.”
John R. Knight, MD, the Center’s founder and director, developed with colleagues a computerized program in 2005, aiming to streamline the screening and counseling process. Teens complete the CRAFFT, a five-minute screening survey, in the waiting room prior to the physician visit. The program shows teens their risk score and provides them with targeted science-based information about the health risks of alcohol use and true-life stories about the impact of substance use on teens.
“It primes the teen for the discussion with the provider and may give that conversation more bang for the buck,” says Harris.
The screening program populates a report for the pediatrician with the teen’s results and provides bullet points to inform a two- to three-minute counseling session. Providers are encouraged to emphasize the risk of substance abuse to the developing brain and counsel patients to stop substance use.
Louis-Jacques and her colleagues devised a study to determine the impact of the program on alcohol cessation (no drinking at follow-up in teens who reported baseline alcohol use) and alcohol initiation (drinking at follow-up in baseline non-drinkers) in 12- to 18-year-olds based on peer risk. The researchers defined a risky peer group as one that approved of or used alcohol or drugs, which is a well-established risk factor for use. A total of 60 percent of the teens in this study reported that they had a risky peer group.
The researchers expected that counseling would be less impactful on teens with a risky peer group. “That’s not what we found, which is so exciting. Our findings can boost providers’ confidence; what they say does make a difference to teens,” Harris says.
In the group with risky peers, those who underwent the computer-facilitated counseling had a 44 percent higher rate of alcohol cessation at three-month follow-up compared with those who underwent treatment as usual. At 12-month follow-up, the counseling intervention had reduced drinking initiation by 31 percent among teens with risky friends.
“Health care providers are in a strong position from which to talk about the health risks of substance use,” says Harris. “This is a unique opportunity that clinicians shouldn’t shy away from.” She adds that the National Institute on Alcohol Abuse and Alcoholism recently published a Youth Screening Guide that recommends always asking preteens and teens whether they have friends who drink.
“The combination of computer feedback and brief pediatrician counseling is a powerful and time-efficient way to put these guidelines into practice, improve adolescent health and save teen lives and futures,” adds Knight.
Are you concerned about drug and alcohol use in your home? Ask your child’s pediatrician about CRAFFT screening, or contact John Knight, MD, and his team at the Center for Adolescent Substance Abuse Research at 617-355-2727, CeASAR@childrens.harvard.edu.