Parent-focused prevention of adolescent health risk behavior: Study protocol for a multisite cluster-randomized trial implemented in pediatric primary care

Pilot Implementation of Guiando Buenas Decisiones, an Evidence-Based Parenting Program for Spanish-Speaking Families, in Pediatric Primary Care in a Large, U.S. Health System: A Qualitative Interview Study

Adolescent substance use is a significant public health problem in the United States and Hispanic youth engage in substance use services at lower rates than other groups. For this under-served group, prevention services delivered in non-stigmatized, non-specialty care settings may increase access to the services. We describe findings from a feasibility pilot of the implementation of a virtual version of Guiando Buenas Decisiones (GBD), a universal, group-based substance use prevention program for parents. It was conducted with Spanish-speaking families and delivered, virtually, in pediatric primary care in a large healthcare system in the U.S. Through qualitative interviews with pediatricians (n =7)  and parents (n = 26), we explored potential barriers and facilitators of GBD enrollment and engagement. Parents and pediatricians alike noted the dearth of universal prevention programming in Spanish and that GBD could help address the need for linguistically appropriate programming. Parents liked the curriculum content, materials and videos; they felt the focus on strengthening family bonds, setting clear expectations and guidelines, the use of family meetings, and the positive tools provided for navigating family conflict were well-aligned with their cultural and family values. Feedback from parents was helpful for informing more personalized and attentive approaches to program outreach and recruitment methods, and for adaptation of recruitment fliers and letters. In this pediatric primary care context serving an underserved population, we found virtual GBD feasible to implement, acceptable and appealing to parents, and judged by pediatricians as a promising, much-needed addition to their prevention armamentarium.

Family-Focused Prevention and Early Intervention of Substance Use in Pediatric Primary Care Settings

Prevention of substance misuse and substance use disorders is a national public health priority. The home environment can represent risk or protective factors for development of substance misuse. Children in homes with caregiver substance use are biologically, developmentally, interpersonally, and environmentally vulnerable to substance misuse and associated consequences, making it necessary for substance use prevention to focus on families early. Children and families who are minoritized, marginalized, and disenfranchised experience disproportionate consequences of substance use, through experiences of poverty, racism, trauma, and the built environment. Strengthening protective factors in early childhood by improving the health of caregivers and supporting the caregiver-child relationship can have enduring benefits over the life course. Pediatric primary care practices are an important setting for adopting a family-focused approach to prevention and early intervention of substance use. By engaging families early, identifying substance use in the family and household, recognizing the intersection of social needs and substance use, providing culturally tailored, trauma-informed, evidence-based care, and advising and supporting families on ways to minimize substance-related harm, pediatric care providers can play an important role in preventing substance use and substance-related consequences to children and families. Pediatric care providers are ideally suited to deliver prevention messages in a nonstigmatizing manner and serve as a conduit to evidence-based, family-focused intervention programs.

Engaging caregivers to prevent substance use by at-risk adolescents in pediatric primary care

PURPOSE OF REVIEW

Improving adolescent substance use prevention and treatment is an urgent public health priority in the United States. Current intervention models do not address how adolescents with a history of caregiver substance use are at particular risk for problematic substance use. We, therefore, reviewed the evidence on adolescent substance use prevention programs integrating caregiver-focused components and propose opportunities to incorporate adaptations of existing programs into pediatric primary care to improve outcomes for at-risk adolescents exposed to caregiver substance use.

RECENT FINDINGS

There are multiple evidence-based universal prevention programs that target adolescent substance use and incorporate caregivers; however, these programs do not address the specific concerns of caregivers with substance use. Caregiver-focused programs efficaciously address family and child risk factors for adolescent substance use but are not accessible to many families and have not been longitudinally studied to assess impact on adolescent substance use.

SUMMARY

Adaptation of existing prevention programs to pediatric primary care settings may open opportunities to improve engagement of families with caregiver substance use in targeted prevention strategies. Family Screening, Brief Intervention, and Referral to Treatment (F-SBIRT) is one model that can be incorporated into pediatric primary care to contextualize evidence-based practices to address substance use in a family-focused approach. To develop F-SBIRT, further research is needed to validate caregiver-focused screening tools, determine brief intervention (BI) best practices, and adapt existing evidence-based and caregiver-focused adolescent prevention programs for use with caregivers with substance use in pediatric primary care settings.

Anxiety, depression, and suicidal ideation among early adolescents during the COVID-19 pandemic

BACKGROUND

Anxiety and depression are among the most common and debilitating psychiatric disorders affecting youth, with both related to increased suicide risk. While rates of youth anxiety and depression were increasing before the COVID-19 pandemic, the pandemic further negatively impacted adolescent mental health. Unfortunately, few studies have examined prevalence of these concerns among early adolescents (ages 10-13) longitudinally during the pandemic.

METHOD

The current study examined self-reported anxiety and depression symptoms, and suicidal ideation amongst a general pediatrics population of 11- to 13-year-olds (n = 623) from March through September 2020 (early-pandemic) and approximately 7 months later (September 2020 through May 2021; mid-pandemic). Paired samples proportions were used to examine changes in prevalence of moderate to severe anxiety, depression, and suicidal ideation from early- to mid-pandemic.

RESULTS

Results highlight high initial rates and stability in anxiety and suicidal ideation, as well as a significant increase in depression (42.9% increase; p < .05) among the full sample during the COVID-19 pandemic. Prevalance of concerns were greatest for females and Hispanic youth during the early-pandemic, and generally highest for females and Medicaid insured youth at mid-pandemic.

DISCUSSION

Results extend recent research and underscore the need for continued monitoring of mental health concerns across development for youth who grew up during the COVID-19 pandemic; highlighting the need for sustainable, effective, and accessible early detection, prevention, and intervention strategies. Improving these services is critical to support youth who experienced pandemic-related stressors, and to prepare for supporting youth during future disruptive and isolating events.

Standard Versus Family-Based Screening, Brief Intervention, and Referral to Treatment for Adolescent Substance Use in Primary Care: Protocol for a Multisite Randomized Effectiveness Trial

BACKGROUND

Screening, brief intervention, and referral to treatment for adolescents (SBIRT-A) is widely recommended to promote detection and early intervention for alcohol and other drug (AOD) use in pediatric primary care. Existing SBIRT-A procedures rely almost exclusively on adolescents alone, despite the recognition of caregivers as critical protective factors in adolescent development and AOD use. Moreover, controlled SBIRT-A studies conducted in primary care have yielded inconsistent findings about implementation feasibility and effects on AOD outcomes and overall developmental functioning. There is urgent need to investigate the value of systematically incorporating caregivers in SBIRT-A procedures.

OBJECTIVE

This randomized effectiveness trial will advance research and scope on SBIRT-A in primary care by conducting a head-to-head test of 2 conceptually grounded, evidence-informed approaches: a standard adolescent-only approach (SBIRT-A-Standard) versus a more expansive family-based approach (SBIRT-A-Family). The SBIRT-A-Family approach enhances the procedures of the SBIRT-A-Standard approach by screening for AOD risk with both adolescents and caregivers; leveraging multidomain, multireporter AOD risk and protection data to inform case identification and risk categorization; and directly involving caregivers in brief intervention and referral to treatment activities.

METHODS

The study will include 2300 adolescents (aged 12-17 y) and their caregivers attending 1 of 3 hospital-affiliated pediatric settings serving diverse patient populations in major urban areas. Study recruitment, screening, randomization, and all SBIRT-A activities will occur during a single pediatric visit. SBIRT-A procedures will be delivered digitally on handheld tablets using patient-facing and provider-facing programming. Primary outcomes (AOD use, co-occurring behavior problems, and parent-adolescent communication about AOD use) and secondary outcomes (adolescent quality of life, adolescent risk factors, and therapy attendance) will be assessed at screening and initial assessment and 3-, 6-, 9-, and 12-month follow-ups. The study is well powered to conduct all planned main and moderator (age, sex, race, ethnicity, and youth AOD risk status) analyses.

RESULTS

This study will be conducted over a 5-year period. Provider training was initiated in year 1 (December 2023). Participant recruitment and follow-up data collection began in year 2 (March 2024). We expect the results from this study to be published in early 2027.

CONCLUSIONS

SBIRT-A is widely endorsed but currently underused in pediatric primary care settings, and questions remain about optimal approaches and overall effectiveness. In particular, referral to treatment procedures in primary care remains virtually untested among youth. In addition, whereas research strongly supports involving families in interventions for adolescent AOD, SBIRT-A effectiveness trial testing approaches that actively engage family members in primary care are absent. This trial is designed to help fill these research gaps to inform the critical health decision of whether and how to include caregivers in SBIRT-A activities conducted in pediatric primary care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05964010; https://www.clinicaltrials.gov/study/NCT05964010.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/54486.

Collecting patient-reported outcome measures in the electronic health record: Lessons from the NIH pragmatic trials Collaboratory

The NIH Pragmatic Trials Collaboratory supports the design and conduct of 27 embedded pragmatic clinical trials, and many of the studies collect patient reported outcome measures as primary or secondary outcomes. Study teams have encountered challenges in the collection of these measures, including challenges related to competing health care system priorities, clinician's buy-in for adoption of patient-reported outcome measures, low adoption and reach of technology in low resource settings, and lack of consensus and standardization of patient-reported outcome measure selection and administration in the electronic health record. In this article, we share case examples and lessons learned, and suggest that, when using patient-reported outcome measures for embedded pragmatic clinical trials, investigators must make important decisions about whether to use data collected from the participating health system's electronic health record, integrate externally collected patient-reported outcome data into the electronic health record, or collect these data in separate systems for their studies.

Family-Focused Universal Substance Use Prevention in Primary Care: Advancing a Pragmatic National Healthcare Agenda

This article advances ideas presented at a National Academies of Sciences, Engineering, and Medicine workshop in 2022 that highlighted clinical practice and policy recommendations for delivering universal, family-focused substance use preventive interventions in pediatric primary care. Pediatric primary care is a natural setting in which to offer families universal anticipatory guidance and links to systematic prevention programming; also, several studies have shown that offering effective parenting programs in primary care is feasible. The article describes a blueprint for designing a pragmatic national agenda for universal substance use prevention in primary care that builds on prior work. Blueprint practice schematics leverage efficacious family-focused prevention programs, identify key program implementation challenges and resources, and emphasize adopting a core element approach and utilizing digital interventions. Blueprint policy schematics specify avenues for improving cross-sector policy and resource alignment and collaboration; expanding, diversifying, and strengthening the prevention workforce; and enhancing financing for family-focused prevention approaches. The article then draws from these schematics to assemble a candidate universal prevention toolkit tailored for adolescent patients that contains four interlocking components: education in positive parenting practices, parent and youth education in substance use risks, a parent-youth structured interaction task, and parent and youth linkage to in-person and web-based prevention resources.

Potential bias and lack of generalizability in electronic health record data: reflections on health equity from the National Institutes of Health Pragmatic Trials Collaboratory

Embedded pragmatic clinical trials (ePCTs) play a vital role in addressing current population health problems, and their use of electronic health record (EHR) systems promises efficiencies that will increase the speed and volume of relevant and generalizable research. However, as the number of ePCTs using EHR-derived data grows, so does the risk that research will become more vulnerable to biases due to differences in data capture and access to care for different subsets of the population, thereby propagating inequities in health and the healthcare system. We identify 3 challenges-incomplete and variable capture of data on social determinants of health, lack of representation of vulnerable populations that do not access or receive treatment, and data loss due to variable use of technology-that exacerbate bias when working with EHR data and offer recommendations and examples of ways to actively mitigate bias.

Normalization of Prevention Principles and Practices to Reduce Substance Use Disorders Through an Integrated Dissemination and Implementation Framework

Major research breakthroughs over the past 30 years in the field of substance use prevention have served to: (1) enhance understanding of pharmacological effects on the central and peripheral nervous systems and the health and social consequences of use of psychoactive substances, particularly for children and adolescents; (2) delineate the processes that increase vulnerability to or protect from initiation of substance use and progression to substance use disorders (SUDs) and, based on this understanding, (3) develop effective strategies and practices to prevent the initiation and escalation of substance use. The challenge we now face as a field is to "normalize" what we have learned from this research so that it is incorporated into the work of those involved in supporting, planning, and delivering prevention programming to populations around the world, is integrated into health and social service systems, and helps to shape public policies. But we wish to go further, to incorporate these effective prevention practices into everyday life and the mind-sets of the public, particularly parents and educators. This paper reviews the advances that have been made in the field of prevention and presents a framework and recommendations to achieve these objectives generated during several meetings of prevention and implementation science researchers sponsored by the International Consortium of Universities for Drug Demand Reduction (ICUDDR) that guides a roadmap to achieve "normalization."