Adolescent Satisfaction with Computer-Assisted Behavioural Risk Screening in Primary Care

Use of computer-assisted self-interview in detection of and referral for depression among adolescents living with HIV at an urban HIV treatment clinic in Uganda: a quasi-experimental study

BACKGROUND

Depression is common among adolescents living with HIV (ALHIV) and impacts their quality of life. However, it is not routinely detected and treated due to a lack of screening tools, coupled with large numbers of clients in the HIV clinics and limited staff. Enabling adolescents to do a self-assessment for depression on a tablet computer could possibly improve the detection of depression in this population. We set out to assess the detection and referral of depression among ALHIV in care in Uganda.

METHODS

This was a quasi-experimental study design with a historical control at Baylor College of Medicine of Children's Foundation. We conducted a retrospective chart review of 425 adolescents covering a 3-month period and documented the proportion screened for depression and referred to the clinic counsellors. From July to September 2022, eligible adolescents aged 10-19 years who had assented and consented self-assessed for depression using a Patient Health Questionnaire-Adolescent on a tablet computer-assisted self-interview (CASI). Adolescents who screened positive had a prompt on the tablet computers referring them to the counsellor for mental healthcare. We compared the proportions of participants screened for depression and referred to counsellors from clinic chart review and on the CASI using paired t-tests.

RESULTS

Out of 425 medical records reviewed, 54% (231/425) were females and the median age was 15 years. Of the participants who self-assessed on the CASI, 52% (222/425) were males and the median age of all participants was 16 years. Self-assessment on the CASI increased the rate of detection of depression from 0% to 23.3%. Of those referred on the CASI, 15% accessed care at the referral point.

CONCLUSION

The use of CASI improves the rate of detection of depression among ALHIV; however, there is a need to address the barriers to effective referral for mental health services.

An Electronic Teen Questionnaire, the eTeenQ, for Risk Behavior Screening During Adolescent Well Visits in an Integrated Health System: Development and Pilot Implementation

Background

Screening for risk behaviors is a routine and essential component of adolescent preventive health visits. Early identification of risks can inform targeted counseling and care. If stored in discrete fields in the electronic health record (EHR), adolescent screening data can also be used to understand risk behaviors across a clinic or health system or to support quality improvement projects.

Objective

Goals of this pilot study were to adapt and implement an existing paper adolescent risk behavior screening tool for use as an electronic data capture tool (the eTeenQ), to evaluate acceptance of the eTeenQ, and to describe the prevalence of the selected risk behaviors reported through the eTeenQ.

Methods

The multidisciplinary project team applied an iterative process to develop the 29-item eTeenQ. Two unique data entry forms were created with attention to (1) user interface and user experience, (2) the need to maintain patient privacy, and (3) the potential to transmit and store data for future use in clinical care and research. Three primary care clinics within a large health system piloted the eTeenQ from August 17, 2020, to August 27, 2021. During preventive health visits for adolescents aged 12 to 18 years, the eTeenQ was completed on tablets and responses were converted to a provider display for teens and providers to review together. Responses to the eTeenQ were stored in a REDCap (Research Electronic Data Capture; Vanderbilt University) database, and for patients who agreed, responses were transferred to an EHR flowsheet. Responses to selected eTeenQ questions are reported for those consenting to research. At the conclusion of the pilot, the study team conducted semistructured interviews with providers and staff regarding their experience using the eTeenQ.

Results

Among 2816 adolescents with well visits, 2098 (74.5%) completed the eTeenQ. Of these, 1811 (86.3%) agreed to store responses in the EHR. Of 1632 adolescents (77.8% of those completing the eTeenQ) who consented for research and remained eligible, 1472 (90.2%) reported having an adult they can really talk to and 1510 (92.5%) reported feeling safe in their community, yet 401 (24.6%) reported someone they lived with had a gun and 172 (10.5%) reported having had a stressful or scary event that still bothered them. In addition, 157 (9.6%) adolescents reported they were or wondered if they were gay, lesbian, bisexual, pansexual, asexual, or other, and 43 (2.6%) reported they were or wondered if they were transgender or gender diverse. Of 11 staff and 7 providers completing interviews, all felt that the eTeenQ improved confidentiality and willingness among adolescents to answer sensitive questions. All 7 providers preferred the eTeenQ over the paper screening tool.

Conclusions

Electronic capture of adolescent risk behaviors is feasible in a busy clinic setting and well accepted among staff and clinicians. Most adolescents agreed for their responses to risk behavior screening to be stored in the EHR.

A systematic review of substance use screening in outpatient behavioral health settings

OBJECTIVE

Despite the frequent comorbidity of substance use disorders (SUDs) and psychiatric disorders, it remains unclear if screening for substance use in behavioral health clinics is a common practice. The aim of this review is to examine what is known about systematic screening for substance use in outpatient behavioral health clinics.

METHODS

We conducted a PRISMA-based systematic literature search assessing substance use screening in outpatient adult and pediatric behavioral health settings in PubMed, Embase, and PsycINFO. Quantitative studies published in English before May 22, 2020 that reported the percentage of patients who completed screening were included.

RESULTS

Only eight articles met our inclusion and exclusion criteria. Reported prevalence of screening ranged from 48 to 100%, with half of the studies successfully screening more than 75% of their patient population. There were limited data on patient demographics for individuals who were and were not screened (e.g., gender, race) and screening practices (e.g., electronic versus paper/pencil administration).

CONCLUSIONS

The results of this systematic review suggest that successful screening for substance use in behavioral health settings is possible, yet it remains unclear how frequently screening occurs. Given the high rates of comorbid SUD and psychopathology, future research is necessary regarding patient and clinic-level variables that may impact the successful implementation of substance use screening. Trial registry A methodological protocol was registered with the PROSPERO systematic review protocol registry (ID: CRD42020188645).

Exploring the Potential of a School-Based Online Health and Wellbeing Screening Tool: Young People's Perspectives

Despite high levels of need, many young people who experience health issues do not seek, access or receive support. Between May and November 2021, using semi-structured interviews, we explored the perspectives of 51 young people (aged 13–14) from two schools who had taken part in a novel online health and wellbeing screening programme, the Digital Health Contact (DHC). One school delivered the DHC during home-learning due to COVID-19 restrictions, whilst the other delivered it in school when restrictions were lifted. The DHC was seen as a useful approach for identifying health need and providing support, and had high levels of acceptability. Young people appreciated the online format of the DHC screening questionnaire and thought this facilitated more honest responses than a face-to-face approach might generate. Completion at home, compared to school-based completion, was perceived as more private and less time-pressured, which young people thought facilitated more honest and detailed responses. Young people’s understanding of the screening process (including professional service involvement and confidentiality) influenced engagement and responses. Overall, our findings afford important insights around young people’s perspectives of participating in screening programmes, and highlight key considerations for the development and delivery of health screening approaches in (and out of) school.

Exploring the potential of a school-based online health and wellbeing screening tool: professional stakeholders' perspectives and experiences

Background

Supporting children and young people’s (CYP) mental and physical health is a global policy priority but detecting need and facilitating access to health services and support is challenging. This paper explores professional stakeholders’ perspectives of the acceptability, utility and effectiveness of a school-based online health and wellbeing screening tool, the Digital Health Contact (DHC). The DHC, delivered by Public Health School Nurses (PHSN), aims to identify, and put in place strategies to support, unmet health needs among CYP.

Methods

We employed a qualitative study design, using semi-structured interviews. Fourteen key stakeholders involved in the design and implementation of the DHC (commissioners, providers, PHSN and healthcare staff, school leaders) were purposively sampled. Data were analysed thematically.

Results

Our analysis generated two key themes: the perceived benefits of the DHC; and challenges in delivering the DHC. Stakeholders perceived the universal application of the DHC with linked follow-up intervention as an effective means of identifying and supporting CYP with unmet needs, and an efficient way to target limited service resources. There were barriers around enabling school engagement in the DHC, typically in terms of logistics, school infrastructure, and perspectives of fit with schools. These barriers were seen as being negated through developing effective working relationships between schools and PHSN. Effective relationships could highlight the potential benefits of participation. Overall, the DHC was seen as a valuable and effective use of resources, with a low burden on school staff.

Conclusions

The DHC, as a universal school-based health and wellbeing screening tool with linked follow-up intervention, has great potential in identifying and supporting unmet health needs among CYP. The perspectives and experiences of those involved in delivering the DHC highlight important considerations which may enable effective implementation and delivery of school screening programmes across other areas.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12748-2.

Attitudes Toward Electronic Sexual Health Assessments Among Adolescents in the Emergency Department

OBJECTIVES

Adolescents account for nearly half of all newly diagnosed sexually transmitted infection (STI) cases in the United States and frequently access health care via emergency departments (EDs). However, there are many barriers to ED-based STI screening. Electronic sexual health assessments may overcome some of these ED-specific barriers. Thus, the objective of this study was to assess adolescent attitudes toward electronic sexual health assessments to guide STI screening in the ED.

METHODS

This was a secondary analysis of data from 2 cross-sectional studies evaluating acceptability of electronic sexual health assessments in the pediatric ED. Study participants completed an electronic questionnaire that elicited sexual behavior information and attitudes toward electronic sexual health assessments. We interrogated the electronic health record to determine if sexual histories were documented, and if so, we assessed patient preference for mode of assessment. We performed multivariable logistic regression to identify demographic factors associated with acceptance of electronic sexual health assessments.

RESULTS

Of the 1159 adolescents surveyed, 935 (80.7%; 95% confidence interval, 78.3-82.9) found electronic assessments an acceptable method by which to provide sexual health information. The majority (n = 874 [75.4%]; 72.8-77.9) reported a preference for electronic assessments over other modes of assessment. Acceptance of electronic assessments was associated with STI-related chief complaint (adjusted odds ratio, 1.7; 1.0-2.7) and private insurance (adjusted odds ratio, 1.8; 1.2-2.7).

CONCLUSIONS

Electronic sexual health assessments are acceptable to adolescents and are an efficient alternative to face-to-face sexual health assessments. Future studies should focus on how best to integrate electronic assessments into the ED workflow.

Implementing the Routine Use of Electronic Mental Health Screening for Youth in Primary Care: Systematic Review

BACKGROUND

Adolescents often present at primary care clinics with nonspecific physical symptoms when, in fact, they have at least 1 mental health or risk behavior (psychosocial) issue with which they would like help but do not disclose to their care provider. Despite global recommendations, over 50% of youths are not screened for mental health and risk behavior issues in primary care.

OBJECTIVE

This review aimed to examine the implementation, acceptability, feasibility, benefits, and barriers of e-screening tools for mental health and risk behaviors among youth in primary care settings.

METHODS

Electronic databases-MEDLINE, CINAHL, Scopus, and the Cochrane Database of Systematic Reviews-were searched for studies on the routine screening of youth in primary care settings. Screening tools needed to be electronic and screen for at least 1 mental health or risk behavior issue. A total of 11 studies that were reported in 12 articles, of which all were from high-income countries, were reviewed.

RESULTS

e-Screening was largely proven to be feasible and acceptable to youth and their primary care providers. Preconsultation e-screening facilitated discussions about sensitive issues and increased disclosure by youth. However, barriers such as the lack of time, training, and discomfort in raising sensitive issues with youth continued to be reported.

CONCLUSIONS

To implement e-screening, clinicians need to change their behaviors, and e-screening processes must become normalized into their workflows. Co-designing and tailoring screening implementation frameworks to meet the needs of specific contexts may be required to ensure that clinicians overcome initial resistances and perceived barriers and adopt the required processes in their work.

Screening for Mental Health Problems in Pediatric Primary Care

Systematic mental health screening is a recommended but controversial process in the pediatricians' behavioral health tool kit. Although the American Academy of Pediatrics and other organizations promote routine behavioral health screening, implementing an effective and sustainable screening program can be challenging. We discuss the rationale for and barriers to screening in pediatric settings, identify accessible validated tools that can be easily incorporated into practice, and suggest a practical strategy for implementing a more accurate screening system for common mental health concerns in pediatric primary care. [Pediatr Ann. 2020;49(10):e421-e425.].

Comparison of YouthCHAT, an Electronic Composite Psychosocial Screener, With a Clinician Interview Assessment for Young People: Randomized Controlled Trial

Background

Psychosocial problems such as depression, anxiety, and substance abuse are common and burdensome in young people. In New Zealand, screening for such problems is undertaken routinely only with year 9 students in low-decile schools and opportunistically in pediatric settings using a nonvalidated and time-consuming clinician-administered Home, Education, Eating, Activities, Drugs and Alcohol, Sexuality, Suicide and Depression, Safety (HEEADSSS) interview. The Youth version, Case-finding and Help Assessment Tool (YouthCHAT) is a relatively new, locally developed, electronic tablet–based composite screener for identifying similar psychosocial issues to HEEADSSS

Objective

This study aimed to compare the performance and acceptability of YouthCHAT with face-to-face HEEADSSS assessment among 13-year-old high school students.

Methods

A counterbalanced randomized trial of YouthCHAT screening either before or after face-to-face HEEADSSS assessment was undertaken with 129 13-year-old New Zealand high school students of predominantly Māori and Pacific Island ethnicity. Main outcome measures were comparability of YouthCHAT and HEEADSSS completion times, detection rates, and acceptability to students and school nurses.

Results

YouthCHAT screening was more than twice as fast as HEEADSSS assessment (mean 8.57 min vs mean 17.22 min; mean difference 8 min 25 seconds [range 6 min 20 seconds to 11 min 10 seconds]; P<.01) and detected more issues overall on comparable domains. For substance misuse and problems at home, both instruments were roughly comparable. YouthCHAT detected significantly more problems with eating or body image perception (70/110, 63.6% vs 25/110, 22.7%; P<.01), sexual health (24/110, 21.8% vs 10/110, 9.1%; P=.01), safety (65/110, 59.1% vs 17/110, 15.5%; P<.01), and physical inactivity (43/110, 39.1% vs 21/110, 19.1%; P<.01). HEEADSSS had a greater rate of detection for a broader set of mental health issues (30/110, 27%) than YouthCHAT (11/110, 10%; P=.001), which only assessed clinically relevant anxiety and depression. Assessment order made no significant difference to the duration of assessment or to the rates of YouthCHAT-detected positive screens for anxiety and depression. There were no significant differences in student acceptability survey results between the two assessments. Nurses identified that students found YouthCHAT easy to answer and that it helped students answer face-to-face questions, especially those of a sensitive nature. Difficulties encountered with YouthCHAT included occasional Wi-Fi connectivity and student literacy issues.

Conclusions

This study provides preliminary evidence regarding the shorter administration time, detection rates, and acceptability of YouthCHAT as a school-based psychosocial screener for young people. Although further research is needed to confirm its effectiveness in other age and ethnic groups, YouthCHAT shows promise for aiding earlier identification and treatment of common psychosocial problems in young people, including possible use as part of an annual, school-based, holistic health check.

Trial Registration

Australian New Zealand Clinical Trials Network Registry (ACTRN) ACTRN12616001243404p; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371422.

Physician Intervention to Positive Depression Screens Among Adolescents in Primary Care

PURPOSE

The objective of this study was to determine the effectiveness of computer-based screening and physician feedback to guide adolescent depression management within primary care.

METHODS

We conducted a prospective cohort study within two clinics of the computer-based depression screening and physician feedback algorithm among youth aged 12-20 years between October 2014 and October 2015 in Marion County (Indianapolis), Indiana.

RESULTS

Our sample included 2,038 youth (51% female; 60% black; mean age = 14.6 years [standard deviation = 2.1]). Over 20% of youth screened positive for depression on the Patient Health Questionnaire-2 and 303 youth (14.8%) screened positive on the Patient Health Questionnaire-9 (PHQ-9). The most common follow-up action by physicians was a referral to mental health services (34.2% mild, 46.8% moderate, and 72.2% severe range). Almost 11% of youth in the moderate range and 22.7% of youth in the severe range were already prescribed a selective serotonin reuptake inhibitor. When predicting mental health service referral, significant predictors in the multivariate analysis included clinic site (40.2% vs. 73.9%; p < .0001) and PHQ-9 score (severe range 77.8% vs. mild range 47.5%; p < .01). Similarly, when predicting initiation of selective serotonin reuptake inhibitors, only clinic site (28.6% vs. 6.9%; p < .01) and PHQ-9 score (severe range 46.7% vs. moderate range 10.6%; p < .001) were significant.

CONCLUSIONS

When a computer-based decision support system algorithm focused on adolescent depression was implemented in two primary care clinics, a majority of physicians utilized screening results to guide clinical care.

Screening for risky behaviour and mental health in young people: the YouthCHAT programme

BACKGROUND

The prevalence of mental health concerns and risky health behaviours among young people is of global concern. A large proportion of young people in New Zealand (NZ) are affected by depression, suicidal ideation and other mental health concerns, but the majority do not access help. For NZ indigenous Māori, the burden of morbidity and mortality associated with mental health is considerably higher. Targeted screening for risky behaviours and mental health concerns among youth in primary care settings can lead to early detection and intervention for emerging or current mental health and psychosocial issues. Opportunistic screening for youth in primary care settings is not routinely undertaken due to competing time demands, lack of context-specific screening tools and insufficient knowledge about suitable interventions. Strategies are required to improve screening that are acceptable and appropriate for the primary care environment. This article outlines the development, utilisation and ongoing evaluation and implementation strategies for YouthCHAT.

YOUTHCHAT

YouthCHAT is a rapid, electronic, self-report screening tool that assesses risky health-related behaviours and mental health concerns, with a 'help question' that enables youth to prioritise areas they want help with. The young person can complete YouthCHAT in the waiting room prior to consultation, and after completion, the clinician can immediately access a summary report which includes algorithms for stepped-care interventions using a strength-based approach. A project to scale up the implementation is about to commence, using a co-design participatory research approach to assess acceptability and feasibility with successive roll-out to clinics. In addition, a counter-balanced randomised trial of YouthCHAT versus clinician-administered assessment is underway at a NZ high school.

CONCLUSION

Opportunistic screening for mental health concerns and other risky health behaviours during adolescence can yield significant health gains and prevent unnecessary morbidity and mortality. The systematic approaches to screening and provision of algorithms for stepped-care intervention will assist in delivering time efficient, early, more comprehensive interventions for youth with mental health concerns and other health compromising behaviours. The early detection of concerns and facilitation to evidence-based interventions has the potential to lead to improved health outcomes, particularly for under-served indigenous populations.

"I Didn't Even Know You Cared About That Stuff": Youths' Perceptions of Health Care Provider Roles in Addressing Bullying

INTRODUCTION

Youth bullying is a critical public health problem, with those exposed to bullying at risk for development of serious sequelae lasting into adulthood. The purpose of this study was to explore youths' perceptions regarding the role that advanced practice nurses and physicians play in addressing bullying.

METHODS

A qualitative descriptive approach was used; focus groups were used to generate study data. Twenty-four adolescents participated in focus groups centered on exploring health care providers' roles in addressing bullying.

RESULTS

Three themes emerged through qualitative analysis: (a) Not sure that's part of their job, (b) That's way too personal, and (c) They couldn't help anyway. Participants described a very limited role for health care providers in addressing bullying.

DISCUSSION

Youths recognized a narrow role for health care providers in addressing bullying, characterizing bullying as a school- or-community-related issue rather than one influencing health.

Adolescents' Perspectives on Personalized E-Feedback in the Context of Health Risk Behavior Screening for Primary Care: Qualitative Study

BACKGROUND

Electronic health screening tools for primary care present an opportunity to go beyond data collection to provide education and feedback to adolescents in order to motivate behavior change. However, there is limited research to guide feedback message development.

OBJECTIVE

The aim of this study was to explore youth perceptions of and preferences for receiving personalized feedback for multiple health risk behaviors and reinforcement for health promoting behaviors from an electronic health screening tool for primary care settings, using qualitative methodology.

METHODS

In total, 31 adolescents aged 13-18 years completed the screening tool, received the electronic feedback, and subsequently participated in individual, semistructured, qualitative interviews lasting approximately 60 min. Participants were queried about their overall impressions of the tool, perceptions regarding various types of feedback messages, and additional features that would help motivate health behavior change. Using thematic analysis, interview transcripts were coded to identify common themes expressed across participants.

RESULTS

Overall, the tool was well-received by participants who perceived it as a way to enhance-but not replace-their interactions with providers. They appreciated receiving nonjudgmental feedback from the tool and responded positively to information regarding the consequences of behaviors, comparisons with peer norms and health guidelines, tips for behavior change, and reinforcement of healthy choices. A small but noteworthy minority of participants dismissed the peer norms as not real or relevant and national guidelines as not valid or reasonable. When prompted for possible adaptations to the tool, adolescents expressed interest in receiving follow-up information, setting health-related goals, tracking their behaviors over time, and communicating with providers electronically between appointments.

CONCLUSIONS

Adolescents in this qualitative study desired feedback that validates their healthy behavior choices and supports them as independent decision makers by neutrally presenting health information, facilitating goal setting, and offering ongoing technological supports.

Research on Clinical Preventive Services for Adolescents and Young Adults: Where Are We and Where Do We Need to Go?

We reviewed research regarding system- and visit-level strategies to enhance clinical preventive service delivery and quality for adolescents and young adults. Despite professional consensus on recommended services for adolescents, a strong evidence base for services for young adults, and improved financial access to services with the Affordable Care Act's provisions, receipt of preventive services remains suboptimal. Further research that builds off successful models of linking traditional and community clinics is needed to improve access to care for all youth. To optimize the clinical encounter, promising clinician-focused strategies to improve delivery of preventive services include screening and decision support tools, particularly when integrated into electronic medical record systems and supported by training and feedback. Although results have been mixed, interventions have moved beyond increasing service delivery to demonstrating behavior change. Research on emerging technology-such as gaming platforms, mobile phone applications, and wearable devices-suggests opportunities to expand clinicians' reach; however, existing research is based on limited clinical settings and populations. Improved monitoring systems and further research are needed to examine preventive services facilitators and ensure that interventions are effective across the range of clinical settings where youth receive preventive care, across multiple populations, including young adults, and for more vulnerable populations with less access to quality care.

Emergency Department Screening for Suicide and Mental Health Risk

Suicide is the second leading cause of death among youth ages 10-24. An estimated 1.5 million US adolescents receive their primary health care in the emergency department (ED); this is particularly true for low-income and minority youths who often lack a regular source of care. ED visits can provide a window of opportunity to screen and identify youths with suicide and mental health risk, triage youths based on need, and facilitate effective follow-up care. Recently developed brief therapeutic assessment approaches have demonstrated success in improving rates of follow-up care after discharge from the ED. Furthermore, there is some data supporting clinical benefits when youths receive evidence-based outpatient follow-up care. ED screening combined with effective follow-up, therefore, may provide one strategy for improving mental health and reducing health disparities in our nation. This paper reviews the context in which ED screenings occur, available tools and strategies, and evidence for the effectiveness of tested approaches.

MEDICAL COMORBIDITY AND COMPLICATIONS

Like their peers in the general youth population, youth with chronic medical conditions (YCMC) are at risk for substance use, including nonmedical use of prescription medications. However, given dangerous disease-substance interactions, the stakes for detecting and intervening on substance use are perhaps even higher for YCMC. Given the risk for nonadherence with chronic disease management, it is incumbent on primary care providers, specialty providers, and behavioral health specialists to be vigilant in asking about substance use and providing brief counseling and referral to substance use treatment when appropriate.

Adolescent substance use screening in primary care: Validity of computer self-administered versus clinician-administered screening

BACKGROUND

Computer self-administration may help busy pediatricians' offices increase adolescent substance use screening rates efficiently and effectively, if proven to yield valid responses. The CRAFFT screening protocol for adolescents has demonstrated validity as an interview, but a computer self-entry approach needs validity testing. The aim of this study was to evaluate the criterion validity and time efficiency of a computerized adolescent substance use screening protocol implemented by self-administration or clinician-administration.

METHODS

Twelve- to 17-year-old patients coming for routine care at 3 primary care clinics completed the computerized screen by both self-administration and clinician-administration during their visit. To account for order effects, we randomly assigned participants to self-administer the screen either before or after seeing their clinician. Both were conducted using a tablet computer and included identical items (any past-12-month use of tobacco, alcohol, drugs; past-3-month frequency of each; and 6 CRAFFT items). The criterion measure for substance use was the Timeline Follow-Back, and for alcohol/drug use disorder, the Adolescent Diagnostic Interview, both conducted by confidential research assistant interview after the visit. Tobacco dependence risk was assessed with the self-administered Hooked on Nicotine Checklist (HONC). Analyses accounted for the multisite cluster sampling design.

RESULTS

Among 136 participants, mean age was 15.0 ± 1.5 years, 54% were girls, 53% were black or Hispanic, and 67% had ≥3 prior visits with their clinician. Twenty-seven percent reported any substance use (including tobacco) in the past 12 months, 7% met criteria for an alcohol or cannabis use disorder, and 4% were HONC positive. Sensitivity/specificity of the screener were high for detecting past-12-month use or disorder and did not differ between computer and clinician. Mean completion time was 49 seconds (95% confidence interval [CI]: 44-54) for computer and 74 seconds (95% CI: 68-87) for clinician (paired comparison, P < .001).

CONCLUSIONS

Substance use screening by computer self-entry is a valid and time-efficient alternative to clinician-administered screening.

Adolescent substance use screening in primary care: Validity of computer self-administered versus clinician-administered screening

BACKGROUND

Computer self-administration may help busy pediatricians' offices increase adolescent substance use screening rates efficiently and effectively, if proven to yield valid responses. The CRAFFT screening protocol for adolescents has demonstrated validity as an interview, but a computer self-entry approach needs validity testing. The aim of this study was to evaluate the criterion validity and time efficiency of a computerized adolescent substance use screening protocol implemented by self-administration or clinician-administration.

METHODS

Twelve- to 17-year-old patients coming for routine care at 3 primary care clinics completed the computerized screen by both self-administration and clinician-administration during their visit. To account for order effects, we randomly assigned participants to self-administer the screen either before or after seeing their clinician. Both were conducted using a tablet computer and included identical items (any past-12-month use of tobacco, alcohol, drugs; past-3-month frequency of each; and 6 CRAFFT items). The criterion measure for substance use was the Timeline Follow-Back, and for alcohol/drug use disorder, the Adolescent Diagnostic Interview, both conducted by confidential research assistant interview after the visit. Tobacco dependence risk was assessed with the self-administered Hooked on Nicotine Checklist (HONC). Analyses accounted for the multisite cluster sampling design.

RESULTS

Among 136 participants, mean age was 15.0 ± 1.5 years, 54% were girls, 53% were black or Hispanic, and 67% had ≥3 prior visits with their clinician. Twenty-seven percent reported any substance use (including tobacco) in the past 12 months, 7% met criteria for an alcohol or cannabis use disorder, and 4% were HONC positive. Sensitivity/specificity of the screener were high for detecting past-12-month use or disorder and did not differ between computer and clinician. Mean completion time was 49 seconds (95% confidence interval [CI]: 44-54) for computer and 74 seconds (95% CI: 68-87) for clinician (paired comparison, P < .001).

CONCLUSIONS

Substance use screening by computer self-entry is a valid and time-efficient alternative to clinician-administered screening.

Adolescent Balloon Analog Risk Task and Behaviors that Influence Risk of Motor Vehicle Crash Injury

Risk-taking propensity is a pivotal facet of motor vehicle crash involvement and subsequent traumatic injury in adolescents. Clinical encounters are important opportunities to identify teens with high risk-taking propensity who may later experience serious injury. Our objective was to compare self-reports of health risk behavior with performance on the Balloon Analog Risk Task (BART), a validated metric of risk-taking propensity, in adolescents during a clinical encounter. 100 adolescent patients from a hospital emergency department and adolescent health clinic completed a computer-based survey of self-reported risk behaviors including substance use behaviors and behaviors that influence crash involvement. They then completed the BART, a validated laboratory-based risk task in which participants earn points by pumping up a computer-generated balloon with greater pumps leading to increased chance of balloon explosion. 20 trials were undertaken. Mean number of pumps on the BART showed a correlation of .243 (p=.015) with self-reported driver/passenger behaviors and attitudes towards driving that influence risk of crash injury. Regression analyses showed that self-reports of substance use and mean number of pumps on the BART uniquely predict self-reports of behaviors influencing the risk of crash injury. The BART is a promising correlate of real-world risk-taking behavior related to traffic safety. It remains a valid predictor of behaviors influencing risk of crash injury when using just 10 trials, suggesting its utility as a quick and effective screening measure for use in busy clinical environments. This tool may be an important link to prevention interventions for those most at-risk for future motor vehicle crash involvement and injury.

Putting the Screen in Screening: Technology-Based Alcohol Screening and Brief Interventions in Medical Settings

Alcohol is strongly linked to the leading causes of adolescent and adult mortality and health problems, making medical settings such as primary care and emergency departments important venues for addressing alcohol use. Extensive research evidence supports the effectiveness of alcohol screening and brief interventions (SBIs) in medical settings, but this valuable strategy remains underused, with medical staff citing lack of time and training as major implementation barriers. Technology-based tools may offer a way to improve efficiency and quality of SBI delivery in such settings. This review describes the latest research examining the feasibility and efficacy of computer- or other technology-based alcohol SBI tools in medical settings, as they relate to the following three patient populations: adults (18 years or older); pregnant women; and adolescents (17 years or younger).The small but growing evidence base generally shows strong feasibility and acceptability of technology-based SBI in medical settings. However, evidence for effectiveness in changing alcohol use is limited in this young field.

Universal mental health screening in pediatric primary care: a systematic review

OBJECTIVE

Universal mental health screening in pediatric primary care is recommended, but studies report slow uptake and low rates of patient follow-through after referral to specialized services. This review examined possible explanations related to the process of screening, focusing on how parents and youth are engaged, and how providers evaluate and use screening results.

METHOD

A narrative synthesis was developed after a systematic review of 3 databases (plus follow-up of citations, expert recommendations, and checks for multiple publications about the same study). Searching identified 1,188 titles, and of these, 186 full-text articles were reviewed. Two authors extracted data from 45 articles meeting inclusion criteria.

RESULTS

Published studies report few details about how mental health screens were administered, including how clinicians explain their purpose or confidentiality, or whether help was provided for language, literacy, or disability problems. Although they were not addressed directly in the studies reviewed, uptake and detection rates appeared to vary with means of administration. Screening framed as universal, confidential, and intended to optimize attention to patient concerns increased acceptability. Studies said little about how providers were taught to explore screen results. Screening increased referrals, but many still followed negative screens, in some cases because of parent concerns apparently not reflected by screen results but possibly stemming from screen-prompted discussions.

CONCLUSIONS

Little research has addressed the process of engaging patients in mental health screening in pediatric primary care or how clinicians can best use screening results. The literature does offer suggestions for better clinical practice and research that may lead to improvements in uptake and outcome.

Assessing the impact of a web-based comprehensive somatic and mental health screening tool in pediatric primary care

OBJECTIVE

To evaluate how parents and physicians perceive the utility of a comprehensive, electronic previsit screener, and to assess its impact on the visit.

METHODS

A mixed methods design was used. English-speaking parents were recruited from 3 primary care systems (urban MD and rural NY and VT) when they presented for a well-child visit with a child 4 to 10 years of age. Parents completed an electronic previsit screen, which included somatic concerns, health risks, and 4 mental health tools (SCARED5, PHQ-2, SDQ Impact, and PSC-17). Parents completed an exit survey, and a subset were interviewed. All primary care providers (PCPs) were interviewed.

RESULTS

A total of 120 parents and 16 PCPs participated. The exit surveys showed that nearly 90% of parents agreed or strongly agreed that the screener was easy to use and maintained confidentiality. During interviews, parents noted that the screener helped with recall, validated concerns, reframed issues they thought might not be appropriate for primary care, and raised new questions. PCPs thought that the screener enabled them to normalize sensitive issues, and it permitted them to simultaneously focus and be comprehensive during the visit. Parents and PCPs agreed that the screener helped guide discussion, promoted in-depth exchange, and increased efficiency. Findings were consistent across quantitative and qualitative methods and between parents and PCPs.

CONCLUSIONS

A comprehensive electronic previsit screening tool is an acceptable and practical strategy to facilitate well-child visits. It may help with problem identification as well as with setting agendas, engaging the family, and balancing attention between somatic and psychosocial concerns.

Health literacy and willingness to use online health information by teens with asthma and diabetes

OBJECTIVE

This study measured health literacy in a population of teens in treatment for asthma or diabetes and tested the association between health literacy and willingness to use online health resources.

MATERIALS AND METHODS

About 180 patients aged 13-18 years treated for asthma or diabetes in specialty care clinics completed assessments of demographic characteristics, health literacy, and Internet access and use. Teens were provided a resource page listing selected publically available health-related Web sites and asked about perceived ease of use, perceived usefulness, and intent to use the listed Web sites. The relationship between demographic characteristics, health literacy, and online health information use was tested using chi-squared or Fisher's exact test. Predictors of intent to use resource page Web sites were assessed using bivariate and multivariate ordinal logistic regression.

RESULTS

About 92% of participants had adequate health literacy. Over 50% of participants had previously searched online for health information. Older age was the only significant predictor of health information search. Most teens (79%) reported intent to use at least one Web site from the resource page at least occasionally within the next 3 months. Higher health literacy (odds ratio [OR]=6.24, p<0.01) and stronger perceived usefulness (OR=1.74, p=0.01) were associated with greater intent for regular use, after controlling for demographic and Internet access variables.

CONCLUSIONS

Teens with lower health literacy searched online for health information as often as peers with higher literacy, but were less likely to express the intent to use recommended sites. Belief in the usefulness of a Web site is the strongest attitudinal predictor of intended future use.

Screening, triage, and referral of patients who report suicidal thought during a primary care visit

OBJECTIVE

Suicidal youths are rarely identified in primary care settings. We describe here a care process that includes a computerized screen, colocated social workers, and a coordinated suicide-prevention team at a specialty mental health unit.

PATIENTS AND METHODS

Patients were 1547 youths aged 11 to 20 years seen in an urban primary care system during 2005 and 2006. We performed an observational study of services provided to youths who screened positive for suicidal ideation on a computerized behavioral health screen during visits to pediatric primary care clinics. Data included clinical records, provider notes, and patients' responses to the screen.

RESULTS

A total of 209 (14%) youths reported suicidal thought in the previous month. Suicidal thought was more common among girls, younger youths, substance users, depressed youths, youths who carried weapons, and those who had been in fights; 87% reported at least 1 other serious behavioral health problem. Social workers were able to triage 205 (98%) youths. Triage occurred on the visit day for 193 youths (94%). Mental health evaluations were recommended for 152 (74%) of the triaged youths. Of the 109 subjects referred to a clinic with records accessible for review, 71 (65%) received a mental health service within 6 months.

CONCLUSIONS

Pediatric primary care is a feasible setting in which to screen for suicidal youths and link them with mental health services. Youths who visit primary care clinics are willing to disclose suicidal ideation on a computerized screen. Youths who screen positive for suicide have many associated behavioral health needs. The use of information technology, colocated physician extenders, and a coordinated team on the mental health side can facilitate rapid, personal contact between the family and mental health service providers, and has the potential to overcome barriers to care for youths with suicidal ideation in the primary care setting.

Adolescent behavioral risk screening and use of health services

This study assessed whether primary care based computerized screening for substance use, mental health issues and suicidal thoughts affects subsequent use of medical and behavioral health care services in adolescents. Administrative claims data were used to determine service use 6 months after a visit where screening could have occurred. Controlling for previous service use, screened youths were more likely to have post screening use than those not screened. Among the screened patients, medical service use did not differ by screening result. However, behavioral service use was higher for screened youths who screened positive for depression or suicidal thoughts.