Validity of the CRAFFT substance abuse screening test among adolescent clinic patients

OBJECTIVE

To determine the accuracy of the CRAFFT substance abuse screening test.

DESIGN

Criterion standard validation study comparing the score on the 6-item CRAFFT test with screening categories determined by a concurrently administered substance-use problem scale and a structured psychiatric diagnostic interview. Screening categories were "any problem" (ie, problem use, abuse, or dependence), "any disorder" (ie, abuse or dependence), and "dependence."

SETTING

A large, hospital-based adolescent clinic.

PARTICIPANTS

Patients aged 14 to 18 years arriving for routine health care.

MAIN OUTCOME MEASURES

The CRAFFT receiver operating characteristic curve, sensitivity, specificity, positive predictive value, and negative predictive value.

RESULTS

Of the 538 participants, 68.4% were female, and 75.8% were from racial and ethnic minority groups. Diagnostic classifications for substance use during the past 12 months were no use (49.6%), occasional use (23.6%), problem use (10.6%), abuse (9.5%), and dependence (6.7%). Classifications were strongly correlated with the CRAFFT score (Spearman rho, 0.72; P<.001). A CRAFFT score of 2 or higher was optimal for identifying any problem (sensitivity, 0.76; specificity, 0.94; positive predictive value, 0.83; and negative predictive value, 0.91), any disorder (sensitivity, 0.80; specificity, 0.86; positive predictive value, 0.53; and negative predictive value, 0.96) and dependence (sensitivity, 0.92; specificity, 0.80; positive predictive value, 0.25; and negative predictive value 0.99). Approximately one fourth of participants had a CRAFFT score of 2 or higher. Validity was not significantly affected by age, sex, or race.

CONCLUSION

The CRAFFT test is a valid means of screening adolescents for substance-related problems and disorders, which may be common in some general clinic populations.

A new brief screen for adolescent substance abuse

OBJECTIVE

To develop a brief alcohol and other drug (AOD) screening test for adolescents.

METHODS

A 9-item test was constructed by combining and modifying items from several AOD assessments, and administered concurrently with the Personal Involvement With Chemicals Scale (PICS), the criterion standard.

SETTING

A hospital-based adolescent clinic.

SUBJECTS

Fourteen- to 18-year-old patients consecutively arriving for routine medical care who were known to have used AOD.

MEASURES

Internal consistency of the 9 items was calculated using the Cronbach alpha. The relationship between the brief screen and PICS raw score was determined by stepwise linear regression analysis. The PICS T score has been shown to correctly classify substance abuse treatment need as no treatment (T<35), brief office intervention (T = 35-40), outpatient or short-term treatment (T = 41-54), and inpatient or long-term treatment (T> or =55). Sensitivity and specificity rates for predicting a PICS T score of 55 or higher were calculated from 2 x 2 tables.

RESULTS

Ninety-nine adolescents were tested (70.7% female, 36.4% black, 32.3% white, 19.2% Hispanic, mean age, 16.3 years). The 9 items had good internal consistency (Cronbach alpha = .79). Stepwise linear regression analysis identified 6 items whose total combined score was highly correlated with PICS (Pearson r = 0.84, P<.01). This model correctly classified 86% of subjects according to the PICS criteria. Two or more yes answers had a sensitivity of 92.3% and specificity of 82.1% for intensive AOD treatment need. The 6 items were arranged into a mnemonic (CRAFFT).

CONCLUSIONS

Further research must confirm the test's psychometric properties in a general clinic population. However, CRAFFT seems promising as a brief AOD screening test.

Associations of depression, self-esteem, and substance use with sexual risk among adolescents

BACKGROUND

Adolescents are the population at highest risk for acquiring sexually transmitted diseases (STDs). Previous research has suggested that mental health problems, including depression and low self-esteem, may play an important role in the development and maintenance of sexual risk behaviors.

METHODS

National Longitudinal Study of Adolescent Health data from baseline interviews of 7th-12th graders reporting sexual intercourse in the preceding year were analyzed. Using logistic regression, associations of depressive symptoms, self-esteem, and substance use with condom nonuse at last sexual intercourse and with ever having had an STD were explored separately for each gender.

RESULTS

Among boys (N = 3,192), depressive symptoms were associated with an increased risk of condom nonuse at last sexual intercourse. The association between depressive symptoms and STD appeared to be mediated by alcohol and marijuana use. For girls (N = 3,391), depressive symptoms were associated with a history of STD, but not with condom nonuse. Self-esteem was not significant in any model that included depressive symptoms.

CONCLUSIONS

Adolescents with depressive symptoms are at risk for not using a condom and for having an STD. Further research is needed to elucidate the relationship among depression, substance use, and sexual risk to optimize STD prevention strategies for adolescents.

Depressive symptoms as a longitudinal predictor of sexual risk behaviors among US middle and high school students

OBJECTIVE

The purpose of this study was to examine whether depressive symptoms are predictive of subsequent sexual risk behavior in a national probability sample of US middle and high school students.

METHODS

Sexually active, unmarried, middle and high school students (n = 4152) participated in home interviews in waves I and II of the National Longitudinal Study of Adolescent Health, at an approximately 1-year interval. Associations between baseline depressive symptoms and sexual risk behaviors over the course of the following year were examined separately for boys and girls, adjusting for demographic variables, religiosity, same-sex attraction/behavior, sexual intercourse before age 10, and baseline sexual risk behavior.

RESULTS

In adjusted models, boys and girls with high depressive symptom levels at baseline were significantly more likely than those with low symptom levels to report > or = 1 of the examined sexual risk behaviors over the course of the 1-year follow-up period. For boys, high depressive symptom levels were specifically predictive of condom nonuse at last sex, birth control nonuse at last sex, and substance use at last sex; these results were similar to those of parallel analyses with a continuous depression measure. For girls, moderate depressive symptoms were associated with substance use at last sex, and no significant associations were found between high depressive symptom levels and individual sexual risk behaviors. Parallel analyses with the continuous depression measure found significant associations for condom nonuse at last sex, birth control nonuse at last sex, > or = 3 sexual partners, and any sexual risk behavior.

CONCLUSION

In this study, depressive symptoms predicted sexual risk behavior in a national sample of male and female middle and high school students over a 1-year period.

The association of sexual risk behaviors and problem drug behaviors in high school students

PURPOSE

To examine the associations among early age of onset of sexual intercourse and drug use, lifetime and current problem drug behaviors, and sexual risk behaviors.

METHODS

The 1993 Massachusetts Youth Risk Behavior Survey was administered to a sample of 3,054 students from randomly selected high schools and classrooms; 36% (1,078) consistently reported having had sexual intercourse. Three indicators of sexual risk behaviors were assessed: (1) number of lifetime sexual partners, (2) number of recent partners, and (3) condom nonuse at last intercourse. Three sets of independent variables were analyzed: (1) age of onset of sexual intercourse and drug use, (2) lifetime drug use, and (3) recent drug use.

RESULTS

Years of sexual intercourse, early age of onset of marijuana and cocaine use, lifetime frequency of marijuana, crack/freebase cocaine and alcohol use, and black race accounted for moderate amounts of the variation in the number of lifetime sexual partners. Years of sexual intercourse, early age of onset of marijuana use and cocaine use, lifetime frequency of crack/freebase and marijuana use, and recent use of cocaine, alcohol, and cigarettes accounted for smaller but significant amounts of the variation in the number of recent partners. Students more likely to report recent condom nonuse were older, females, had more years of sexual intercourse, had tried cocaine at a younger age, had used marijuana and cocaine more times (lifetime), and had more frequent recent use of marijuana.

CONCLUSION

Increased frequency and severity of drug use behaviors and more years of sexual intercourse are associated with an increased number of sexual partners and recent condom nonuse. These findings may guide history-taking and referral practices of health care providers. Programs designed to prevent sexually transmitted diseases and pregnancy should address drug use as well as sexual behavior.

An electronic screen for triaging adolescent substance use by risk levels

IMPORTANCE

Screening adolescents for substance use and intervening immediately can reduce the burden of addiction and substance-related morbidity. Several screening tools have been developed to identify problem substance use for adolescents, but none have been calibrated to triage adolescents into clinically relevant risk categories to guide interventions.

OBJECTIVE

To describe the psychometric properties of an electronic screen and brief assessment tool that triages adolescents into 4 actionable categories regarding their experience with nontobacco substance use.

DESIGN, SETTING, AND PARTICIPANTS

Adolescent patients (age range, 12-17 years) arriving for routine medical care at 2 outpatient primary care centers and 1 outpatient center for substance use treatment at a pediatric hospital completed an electronic screening tool from June 1, 2012, through March 31, 2013, that consisted of a question on the frequency of using 8 types of drugs in the past year (Screening to Brief Intervention). Additional questions assessed severity of any past-year substance use. Patients completed a structured diagnostic interview (Composite International Diagnostic Interview-Substance Abuse Module), yielding Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) substance use diagnoses.

MAIN OUTCOMES AND MEASURES

For the entire screen and the Screening to Brief Intervention, sensitivity and specificity for identifying nontobacco substance use, substance use disorders, severe substance use disorders, and tobacco dependence were calculated using the Composite International Diagnostic Interview-Substance Abuse Module as the criterion standard.

RESULTS

Of 340 patients invited to participate, 216 (63.5%) enrolled in the study. Sensitivity and specificity were 100% and 84% (95% CI, 76%-89%) for identifying nontobacco substance use, 90% (95% CI, 77%-96%) and 94% (95% CI, 89%-96%) for substance use disorders, 100% and 94% (95% CI, 90%-96%) for severe substance use disorders, and 75% (95% CI, 52%-89%) and 98% (95% CI, 95%-100%) for nicotine dependence. No significant differences were found in sensitivity or specificity between the full tool and the Screening to Brief Intervention.

CONCLUSIONS AND RELEVANCE

A single screening question assessing past-year frequency use for 8 commonly misused categories of substances appears to be a valid method for discriminating among clinically relevant risk categories of adolescent substance use.

Supportive relationships and sexual risk behavior in adolescence: an ecological-transactional approach

OBJECTIVE

To examine the longitudinal associations between supportive relationships with friends and parents and sexual risk behavior in adolescence based on an ecological-transactional perspective.

METHODS

Analyses were conducted on 2,652 sexually active adolescents from the first two waves of the National Longitudinal Study of Adolescent Health (Add Health).

RESULTS

African-American adolescents had lower risk for sexual risk behavior. Supportive friendships and parent connectedness interacted in predicting decreased likelihood of sexual risk behavior. Mother-child communication about sex contributed to decreased likelihood of sexual risk only for girls. There were also small reciprocal effects of sexual risk behavior on decreased relationship quality over time.

CONCLUSION

To better understand the parents' role in adolescent sexual risk behavior, multiple facets of parenting, the social contexts of parenting and adolescents' peers, and the effects of adolescents' behavior on these relationships should be taken into consideration.

Temporal associations between depressive symptoms and self-reported sexually transmitted disease among adolescents

OBJECTIVE

To examine the longitudinal associations between depressive symptoms and self-reported sexually transmitted disease (STD) diagnosis among adolescents.

SETTING AND PARTICIPANTS

National Longitudinal Study of Adolescent Health data were analyzed for 7th through 12th graders who reported having sexual intercourse between baseline (Wave 1) and 1-year follow-up (Wave 2) in-home interviews (N = 4738 [2232 boys, 2506 girls]). The association between level of depressive symptoms at Wave 1 and self-reported diagnosis of STD between Wave 1 and Wave 2 was explored separately for boys and girls using logistic regression that controlled for age, race/ethnicity, virginity, and history of STD at Wave 1. Alcohol and marijuana use were assessed as potential mediators. The association between interval STD diagnosis and subsequent very high levels of depressive symptoms (predictive of major depression) was also examined separately by sex controlling for demographic characteristics and baseline depressive symptoms.

MAIN OUTCOME MEASURES

Self-reported STD diagnosis and depressive symptoms.

RESULTS

For boys and girls, higher frequency of depressive symptoms at baseline predicted increased risk of being diagnosed as having an STD within 1 year. After adjusting for history of STD, the association was no longer significant for girls. Alcohol and marijuana use did not mediate this association for either sex, although very frequent alcohol use was an independent predictor of STD diagnosis for boys. For boys and girls, being diagnosed as having an STD within 1 year was associated with very high levels of depressive symptoms at the end of that year in both bivariate and multivariate models.

CONCLUSIONS

Screening for depressive symptoms in sexually active adolescents, particularly boys, may identify those at risk for STDs. In addition, adolescents who are diagnosed as having STDs should be monitored for depression. These findings suggest that adolescent preventive care needs to include regular, comprehensive assessments of both mental health and STD.

Depressive symptomatology as a predictor of exposure to intimate partner violence among US female adolescents and young adults

OBJECTIVE

To examine whether depressive symptomatology is predictive of subsequent intimate partner violence victimization among a national prospective sample of female adolescents and young adults.

DESIGN

Home interview data from 2 waves of the school-based National Longitudinal Study of Adolescent Health were used to examine whether baseline depressive symptomatology was associated with increased risk of past-year exposure to physical abuse by a current partner at 5-year follow-up, controlling for age, race/ethnicity, parental education, retrospective childhood physical and sexual abuse, and baseline dating violence and forced sex.

SETTING

A stratified random sample of 80 US high schools and 52 middle schools.

PARTICIPANTS

All young women (n = 1659) were in a current opposite-sex relationship at follow-up.

MAIN EXPOSURE

Baseline past-week depressive symptomatology, measured as both a dichotomous and continuous variable.

MAIN OUTCOME MEASURES

Past-year exposure to mild and moderate to severe physical abuse by a current intimate partner.

RESULTS

In adjusted models with dichotomous depressive symptoms, high baseline symptom levels were associated with 1.86 times the odds of subsequent exposure to moderate to severe partner violence (95% confidence interval, 1.05-3.29). In adjusted models with continuous depressive symptoms, an increase of 1 SD in baseline symptom levels was associated with a 24% increase in odds of exposure to mild partner violence and a 24% increase in the odds of exposure to moderate to severe partner violence.

CONCLUSIONS

The findings of this study suggest that depressive symptomatology among girls during adolescence is associated with increased risk of subsequent exposure to physical partner violence. Prevention, identification, and treatment of depressive symptomatology among adolescent girls may help to reduce the likelihood of subsequent victimization.

Randomized controlled trial of a safer sex intervention for high-risk adolescent girls

OBJECTIVE

To determine the effect of an individualized safer sex intervention on condom use and recurrent sexually transmitted disease (STD) among female adolescents diagnosed as having an STD.

DESIGN

Randomized controlled trial.

SETTING

Urban children's hospital adolescent clinic and inpatient service.

PARTICIPANTS

One hundred twenty-three adolescents with cervicitis or pelvic inflammatory disease.

INTERVENTION

Participants completed a questionnaire and then were randomized to receive standard STD education or to watch a videotape and have an individualized intervention session. Follow-up questionnaires were completed at 1, 3, 6, and 12 months. Intervention participants met with an educator at 1, 3, and 6 months to discuss interim sexual history and review the intervention.

MAIN OUTCOME MEASURES

Change in self-reported condom use and recurrence of STD. Other self-reported behaviors, sexual risk knowledge, attitudes toward condoms, and condom use negotiation skills were also assessed.

RESULTS

At 1 month, compared with control participants, intervention participants had increased sexual risk knowledge and more positive attitudes toward condoms and tended to use condoms more with a nonmain partner. At 6 months, fewer intervention participants than controls had sex with a nonmain sexual partner in the previous 6 months. At 12 months, intervention participants were less likely to have a current main partner and had a lower rate of recurrent STD than controls, but these differences were not significant.

CONCLUSIONS

This individualized safer sex intervention may improve condom use and decrease the number of partners among adolescent girls who have had an STD. Studies with larger samples are needed to determine definitive intervention effects on recurrent STD in this high-risk population.

Substance use problems and associated psychiatric symptoms among adolescents in primary care

OBJECTIVE

Substance use disorders (SUDs) are associated with other mental disorders in adolescence, but it is unclear whether less severe substance use problems (SUPs) also increase risk. Because youths with SUPs are most likely to present first to their site of primary care, it is important to establish the presence and patterns of psychiatric comorbidity among adolescent primary care patients with subdiagnostic use of alcohol or other drugs. The objective of this study was to determine the association between level of substance use and psychiatric symptoms among adolescents in a primary care setting.

METHODS

Patients who were aged 14 to 18 years and receiving routine care at a hospital-based adolescent clinic were eligible. Participants completed the Problem Oriented Screening Instrument for Teenagers Substance Use/Abuse scale, which is designed to detect social and legal problems associated with alcohol and other drugs, and the Adolescent Diagnostic Interview, which evaluates for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnoses of substance abuse/dependence and 8 types of psychiatric symptoms. We examined gender-specific associations of no/nonproblematic substance use (NSU), SUP, and SUD with psychiatric symptom presence (any symptoms within each type), score (symptom scores summed across all types), and number of types (number of different symptom types endorsed).

RESULTS

Of 538 adolescents (68% female; mean +/- standard deviation age: 16.6 +/- 1.4 years), 66% were classified with NSU, 18% with SUP, and 16% with SUD, and 80% reported having at least 1 type of psychiatric symptom in the previous 12 months. Symptoms of anxiety were most common (60% of both boys and girls), followed by symptoms of depression among girls (51%) and symptoms of attention-deficit disorder (ADD) among boys (47%). Compared with those with NSU, youths with SUP and those with SUD were more likely to report symptom presence for several types of psychiatric symptoms. Girls with SUP or SUD had increased odds of reporting symptoms of mania, ADD, and conduct disorder; girls with SUD were at increased risk for symptoms of depression, eating disorders, and hallucinations or delusions. Boys with SUP had increased odds of ADD symptoms, whereas boys with SUD had increased odds of reporting hallucinations or delusions. Boys with SUP or SUD had increased odds of reporting symptoms of conduct disorder. Youths with SUP and SUD also had higher psychiatric symptom scores and reported a wider range of psychiatric symptom types (number of types) compared with youths with NSU.

CONCLUSIONS

Like those with SUD, adolescents with subdiagnostic SUP were at increased risk for experiencing a greater number of psychiatric symptoms and a wider range of psychiatric symptom types than youths with NSU. Specifically, adolescents with SUP are at increased risk for symptoms of mood (girls) and disruptive behavior disorders (girls and boys). These findings suggest the clinical importance of SUP and support the concept of a continuum between subthreshold and diagnostic substance use among adolescents in primary care. Identification of youths with SUP may allow for intervention before either the substance use or any associated psychiatric problems progress to more severe levels.

Characteristics of screen media use associated with higher BMI in young adolescents

OBJECTIVES

This study investigates how characteristics of young adolescents' screen media use are associated with their BMI. By examining relationships between BMI and both time spent using each of 3 screen media and level of attention allocated to use, we sought to contribute to the understanding of mechanisms linking media use and obesity.

METHODS

We measured heights and weights of 91 13- to 15-year-olds and calculated their BMIs. Over 1 week, participants completed a weekday and a Saturday 24-hour time-use diary in which they reported the amount of time they spent using TV, computers, and video games. Participants carried handheld computers and responded to 4 to 7 random signals per day by completing onscreen questionnaires reporting activities to which they were paying primary, secondary, and tertiary attention.

RESULTS

Higher proportions of primary attention to TV were positively associated with higher BMI. The difference between 25th and 75th percentiles of attention to TV corresponded to an estimated +2.4 BMI points. Time spent watching television was unrelated to BMI. Neither duration of use nor extent of attention paid to video games or computers was associated with BMI.

CONCLUSIONS

These findings support the notion that attention to TV is a key element of the increased obesity risk associated with TV viewing. Mechanisms may include the influence of TV commercials on preferences for energy-dense, nutritionally questionable foods and/or eating while distracted by TV. Interventions that interrupt these processes may be effective in decreasing obesity among screen media users.

Body modification and substance use in adolescents: is there a link?

PURPOSE

To describe the characteristics of body modification among adolescents and to determine whether adolescents who engage in body modification are more likely to screen positive for alcohol and other drug problems than those who do not.

METHODS

Adolescents aged 14 to 18 years presenting to an urban adolescent clinic for routine health care completed a questionnaire about body modification and a substance use assessment battery that included the 17-item Problem Oriented Screening Instrument for Teenagers Alcohol/Drug Use and Abuse Scale (POSIT-ADS). Body modification was defined as piercings (other than one pair of bilateral earlobe piercings in females), tattoos, scarification, and branding. Problem substance use was defined as a POSIT-ADS score > or =1. Data were analyzed using logistic regression to determine whether the presence of body modification was an independent predictor of problem substance use.

RESULTS

The 210 participants had a mean (+/- SD) age of 16.0 (+/- 1.4) years and 63% were female. One hundred adolescents (48%) reported at least one body modification; girls were more likely than boys to have body modification (59% vs. 28%, p < or = .0005). Ninety (42%) reported piercings, 22 (10%) tattoos, 9 (4%) scarification, and 1 (< 1%) branding; 21 (10%) had more than one type of body modification. These were in a variety of locations, most commonly the ear and the nose (piercings) or the extremities (tattoos). One-third of the sample (33%) screened positive for problem substance use on the POSIT-ADS questionnaire. Controlling for age, adolescents with body modification had 3.1 times greater odds of problem substance use than those without body modification (95% CI 1.7, 5.8).

CONCLUSIONS

Body modification was associated with self-reported problem alcohol and other drug use among middle adolescents presenting for primary care. More research is needed to determine the clinical and sociocultural significance of body modification and its relationship to substance use in this population.

A mobile phone program to track young people's experiences of mood, stress and coping. Development and testing of the mobiletype program

BACKGROUND

Research examining adolescent mood, stresses, and coping has tended to use retrospective questionnaires which are affected by recall biases. The aim of this study was to develop, pilot, and evaluate a youth-friendly mobile phone program to monitor, in real-time, young people's everyday experiences of mood, stress, and their coping behaviours.

METHOD AND DESIGN

A momentary sampling program was designed for mobile phones, and ran for 7 days, administering a brief questionnaire four random times each day, capturing information on current activity, mood, responses to negative mood, stresses, alcohol and cannabis use. Eleven high school students reviewed the program in focus groups, and 18 students completed 7 days of monitoring.

RESULTS

Engagement with the mobiletype program was high with 76% of 504 possible entries completed and 94% (17/18) of the participants reporting that the program adequately captured their moods, thoughts, and activities. The mobiletype program captured meaningful and analyzable data on the way young people's moods, stresses, coping strategies, and alcohol and cannabis use, vary both between and within individuals.

CONCLUSIONS

The mobiletype program captured a range of detailed and interesting qualitative and quantitative data about young people's everyday mood, stresses, responses, and general functioning.

Gender differences in risk behaviors associated with forced or pressured sex

OBJECTIVE

To determine whether gender-specific patterns of risk behaviors are associated with a self-reported history of ever having been forced or pressured to have sexual intercourse among sexually active adolescents.

SUBJECTS AND METHODS

In 1995, 21,297 eighth- through 12th-grade students in 79 public and private schools in Vermont were anonymously surveyed. Data were analyzed for 7884 sexually active students (3931 girls and 3953 boys). Demographic variables and indicators of violence, suicide, recent substance use, sexual behavior, pregnancy, and weight control behavior were assessed. Data were analyzed with multiple logistic regression.

RESULTS

Of the sexually active students, 30.3% of the girls and 9.9% of the boys reported ever being forced or pressured to have sexual intercourse. Among sexually active girls, being in 1 or more physical fights in the past year (odds ratio [OR], 1.65; 95% confidence interval [CI], 1.40-1.94), seriously considering suicide (OR, 1.97; CI, 1.69-2.31), more years of sexual activity (OR, 1.52; CI, 1.43-1.61), not using a condom at last sexual intercourse (OR, 1.28; CI, 1.09-1.49), and having been pregnant more often (OR, 1.40; CI, 1.16-1.69) were associated with having been forced or pressured to have sex. For sexually active boys, seriously considering suicide (OR, 1.64; CI, 1.23-2.20), more years of sexual activity (OR, 1.21; CI, 1.12-1.31), more male partners in the past 3 months (OR, 1.30; CI, 1.14-1.48), more female partners in the past 3 months (OR, 1.09; CI, 1.01-1.18), not using a condom at last sexual intercourse (OR, 1.37; CI, 1.03-1.82), having been involved in more pregnancies (OR, 1.64; CI, 1.29-2.08), and having vomited or used laxatives (OR, 3.44; CI, 2.18-5.43) were associated with having been forced or pressured to have sex.

CONCLUSIONS

Patterns of risk behaviors differed among sexually active male and female adolescents reporting being forced or pressured to have sex. Having been forced or pressured to have sex was associated with externalizing behavior, such as fighting, among girls and with internalizing behavior, such as bulimia, among boys. These unexpected associations have notable implications for screening adolescents for a history of having been forced or pressured to have sex.

Condom effectiveness against non-viral sexually transmitted infections: a prospective study using electronic daily diaries

OBJECTIVES

To prospectively evaluate the protective value of consistent and correct use of latex condoms against the acquisition of Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis.

METHODS

Patients (N=929) attending clinics that treat sexually transmitted infections (STIs) were prospectively followed for up to 6 months. Urine STI nucleic acid amplification testing was performed at baseline, 3 months and 6 months. Participants were instructed to respond to daily prompts from a handheld device by completing a report for each penile-vaginal sexual intercourse event. Generalised estimating equation models examined associations of consistent as well as consistent and correct condom use with STI incidence over 3-month intervals.

RESULTS

Consistent condom use was not significantly associated with STI incidence (Estimated OR (EOR)=0.75; 95% CI (CI) 0.43 to 1.30; p=0.31). However, individuals who used condoms both correctly and consistently were estimated to have 59% lower odds of acquiring an STI (EOR=0.41; 95% CI  0.19 to 0.90; p=.026), compared to those who did not.

CONCLUSIONS

The correct as well as the consistent use of condoms greatly reduces the odds of non-viral STI acquisition.

Race and gender differences in the association of dieting and gains in BMI among young adults

OBJECTIVE

To assess the relationship between dieting and subsequent weight change and whether the association varies by gender or race/ethnicity.

RESEARCH METHODS AND PROCEDURES

Male (n = 4100) and female (n = 4302) participants in the National Longitudinal Study of Adolescent Health who provided information on weight and height at baseline and two follow-up assessments and were not missing information on weight control strategies or race were studied. Generalized estimating equations were used to assess whether dieting to lose or maintain weight at Wave I or II predicted BMI (kg/m(2)) change between adolescence and young adulthood (Wave II to III). Analyses were stratified by gender and took sampling weights and clustering into account.

RESULTS

At Wave I, the mean age of the participants was 14.9 years. Approximately 29.3% of female participants and 9.8% of male participants reported dieting in Wave I or II. Fewer African Americans than whites (6.2% vs. 10.0% and 25.5% vs. 31.2%, p = 0.007 and p = 0.02, among males and females, respectively) reported dieting. Between Waves II and III, participants gained on average 3.3 kg/m(2). Independent of BMI gain during adolescence (Waves I to II), female participants who dieted to lose or maintain weight during adolescence made larger gains in BMI during the 5 years between Waves II and III (mean additional gain, 0.39 kg/m(2); 95% confidence interval, 0.08 to 0.71) than their nondieting peers. The association was not significant among the male participants. The association was largest among African-American female participants.

DISCUSSION

The results suggest that not only is dieting to lose weight ineffective, it is actually associated with greater weight gain, particularly among female adolescents. Female African-American dieters made the largest BMI gains.

Affect and sexual behavior in adolescents: a review of the literature and comparison of momentary sampling with diary and retrospective self-report methods of measurement

OBJECTIVE

Assessment of mental health is important in understanding sexual risk behavior in adolescents, yet few studies have examined how affect is directly related to sexual behavior. Momentary sampling (MS) methods permit real-time assessment of affect in relation to specific events and embed the collected data in the context of the respondent's moment-to-moment life. The objectives of this study were to review the literature on affect and sexual behavior and to compare the feasibility and acceptability of MS with diaries and retrospective self-report as a means of collecting temporally relevant data on affect and sexual behavior in adolescents.

METHODS

Sexually active, nondepressed adolescent outpatients who were aged 15 to 18 years were randomly assigned to a schedule of the 3 methods of data collection for 2 weeks each. All participants completed a retrospective self-report by interview at the end of each 2-week period. In the diary arm, participants completed twice-daily paper-and-pencil diary cards, which were returned by mail. In the MS arm, participants used 2-way pagers to respond to several random pages per day. Primary outcomes included rates of completion (diaries vs MS reports) and the participants' tolerance of and preferences for the methods. A secondary outcome was the agreement in means for positive and negative affect and in report of days on which substance use and sexual activity occurred. Associations of affect with contextual factors and with sexual activity were also explored in the MS arm.

RESULTS

Ten youths completed 30 of 30 retrospective self-reports (100%, 3 per participant, by design), 254 of 280 diaries (91%; mean: 25.4 per participant), and 442 of 600 MS reports (74%; mean: 44.2 per participant). Most participants preferred the MS method to the diaries or retrospective self-report. Affect scores and reports of sexual activity and substance use were correlated among the methods. Measured with MS, affect was found to differ by location, companionship, and thoughts when paged; notably, positive affect was highest when participants reported thoughts about sex. There was no difference in affect before versus after coitus.

CONCLUSIONS

The results of this study suggest that MS in adolescents is feasible and preferred and provides contextual, temporally relevant, event-level data on affect and sexual activity that are not readily measured with traditional methods. Future research using MS methods will be important in increasing our understanding of the link between affect and sexual behavior and inform the development of improved risk reduction interventions for adolescents.

Real-time, contextual intervention using mobile technology to reduce marijuana use among youth: a pilot study

We evaluated the feasibility, acceptability, and potential efficacy of MOMENT, an intervention to reduce youth marijuana use that combines brief motivational enhancement therapy with mobile self-monitoring and responsive messaging. At baseline, primary care patients ages 15-24 who used marijuana frequently (at least 3 times per week) completed a recall assessment, then 1 week of mobile momentary and daily reports on use-related factors. For the intervention, youth participated in two motivational enhancement therapy sessions, during which they identified their top-3 social and emotional triggers for use and discussed healthy ways to manage them. They then completed two weeks of mobile reports. Upon reporting a top-3 trigger for use, desire to use, or recent use, they received a message supporting self-efficacy and prompting consideration of coping strategies. Generalized estimating equations examined changes in momentary-, daily-, and individual-level measures on 3-month recall and mobile assessments. Twenty-seven youth (M=19.2 years, 70% female) enrolled; there were 377-677 momentary and 50-106 daily reports per study phase. Participants reported reading the messages and finding them motivating, being comfortable with participation, and not experiencing the study as burdensome. Although proportion of momentary reports of being in a top-3 trigger context did not change (36%-43%), marijuana desire in a top-3 trigger context and marijuana use after top-3 trigger exposure decreased over the study (p<.0001 and p=.03, respectively). Daily- and individual-level measures showed similar, non-significant, improvements. The MOMENT intervention appears feasible, well-accepted, and potentially efficacious for youth who use marijuana frequently.

A momentary sampling study of the affective experience following coital events in adolescents

PURPOSE

To describe the affective experience following sexual intercourse among sexually active adolescents. We hypothesized that these youth would experience more positive and less negative affects following sexual intercourse than at other times in their daily lives.

METHODS

Approximately every 3 waking hours, sexually active adolescents aged 15-21 years used a handheld computer to report current affect and recent sexual intercourse in response to random signals. Participants also completed a report after sexual intercourse. Affect was determined by eight states, as well as composite variables for positive and negative affect. Generalized estimating equations compared affect on reports that did and did not include sexual intercourse. Each model included average affect, affect variability (standard deviation), and significant interactions with the occurrence of sexual intercourse. Based on their distribution, outcome variables were modeled as presence/absence of affect.

RESULTS

Sixty-seven youth completed 1385 random and 392 event reports. There were 266 unique coital reports (median 2.6/participant/week); 94% were with a main partner and 49% involved condom use. Youth were more likely to report positive affect and less likely to report negative affect when they were also reporting recent sexual intercourse, as compared to noncoital reports. In multivariate analyses, participants had greater odds of reporting well being and alertness and lower odds of reporting stress and anger following sexual intercourse compared to other times.

CONCLUSIONS

Adolescents report improvement in specific positive and negative affective states following sexual intercourse. Determining how feeling more positive and less negative after sexual intercourse may motivate or reinforce sexual intercourse will be important in understanding adolescent sexual behavior.

Screening adolescents for substance use-related high-risk sexual behaviors

PURPOSE

This analysis was undertaken to determine whether adolescents who screened positive for high-risk substance use with the CRAFFT questions were also more likely to engage in risky sexual behaviors than their peers, and to determine the test-retest reliability of a substance use-related sexual risk behaviors inventory.

METHODS

Clinic patients 12-18 years old completed a multi-part questionnaire that included eight demographic items, the CRAFFT substance use screen, and a 14-item scale assessing sexual behaviors associated with substance use. Participants were invited to return 1 week later to complete an identical assessment battery.

RESULTS

Of the 305 study participants, 49 (16.1%) had a positive CRAFFT screen result (score of 2 or greater, indicating high risk for substance abuse/dependence) and 101 (33.9%) reported sexual contact during the past 90 days. After controlling for gender, age, race/ethnicity, and number of parents in household, adolescents with a positive CRAFFT screen had significantly greater odds of having sexual contact after using alcohol or other drugs, of having a sexual partner who used alcohol or other drugs, of having sex without a condom, and of having multiple sexual partners within the past year, compared to their CRAFFT negative peers. The substance use-related sexual risk behaviors inventory has acceptable test-retest reliability, and the 10 frequency questions have scale-like properties with acceptable internal consistency (standardized Cronbach's alpha=.79).

CONCLUSION

Clinicians should pay special attention to counseling CRAFFT-positive adolescents regarding use of condoms and the risks associated with sexual activity with multiple partners, while intoxicated, or with an intoxicated partner.

Pilot randomized trial of MOMENT, a motivational counseling-plus-ecological momentary intervention to reduce marijuana use in youth

BACKGROUND

Ecological momentary interventions (EMIs) influence behavior in real time, in real life. We evaluated trial feasibility and preliminary efficacy of MOMENT, a counseling-plus-EMI to reduce frequent marijuana use in youth in primary care.

METHODS

Primary care patients age 15-24 years using marijuana at least 3 times/week were randomized to MOMENT [motivational enhancement therapy (MET)/smartphone-based momentary assessment/responsive motivational messaging] vs. No-messages (MET/momentary assessment) vs. MET-only. In MOMENT, two MET sessions were followed by 2 weeks of momentary assessment of marijuana use and factors related to use, with motivational messaging displayed after report of marijuana triggers, desire, use, and effort to avoid use. We evaluated study feasibility (recruitment, retention, and response rates; feedback survey responses) and explored intervention effects on marijuana desire and use at three months with linear mixed effects modeling.

RESULTS

Seventy youth [mean (M) =20.7 years, 60% female] were assigned to MOMENT (n=27), No-messages (n=15; assignment suspended to enrich other arms), or MET-only (n=28). Most attrition occurred during baseline, before MET. Of those completing MET session 1, 82% completed their assigned treatment and 79% provided 3-month data. Participants highly rated acceptability; comments reflected changing motivation and behavior. Across arms, participants reported significantly lower marijuana use, desire, and problems at follow-up vs. baseline. Momentary marijuana desire declined more in MOMENT vs. MET-only. Marijuana use following a targeted context or behavior was less likely in MOMENT and No-messages, vs. MET-only.

CONCLUSIONS

The MOMENT intervention is feasible to deliver, acceptable, and potentially efficacious in reducing marijuana desire and use among adolescent and young adults in primary care. A larger randomized trial to evaluate efficacy is warranted.

Reliability and validity of the brief multidimensional measure of religiousness/spirituality among adolescents

BACKGROUND

Developed for use in health research, the Brief Multidimensional Measure of Religiousness/Spirituality (BMMRS) consists of brief measures of a broad range of religiousness and spirituality (R/S) dimensions. It has established psychometric properties among adults, but little is known about its appropriateness for use with adolescents.

PURPOSE

We assessed the psychometric properties of the BMMRS among adolescents.

METHOD

We recruited a racially diverse (85% non-White) sample of 305 adolescents aged 12-18 years (median 16 yrs, IQR 14-17) from 3 urban medical clinics; 93 completed a retest 1 week later. We assessed internal consistency and test-retest reliability. We assessed construct validity by examining how well the measures discriminated groups expected to differ based on self-reported religious preference, and how they related to a hypothesized correlate, depressive symptoms. Religious preference was categorized into "No religion/Atheist" (11%), "Don't know/Confused" (9%), or "Named a religion" (80%).

RESULTS

Responses to multi-item measures were generally internally consistent (alpha > or = 0.70 for 12/16 measures) and stable over 1 week (intraclass correlation coefficients > or = 0.70 for 14/16). Forgiveness, Negative R/S Coping, and Commitment items showed lower internal cohesiveness. Scores on most measures were higher (p < 0.05) among those who "Named a religion" compared to the "No religion/Atheist" group. Forgiveness, Commitment, and Anticipated Support from members of one's congregation were inversely correlated with depressive symptoms, while BMMRS measures assessing negative R/S experiences (Negative R/S Coping, Negative Interactions with others in congregation, Loss in Faith) were positively correlated with depressive symptoms.

CONCLUSIONS

These findings suggest that most BMMRS measures are reliable and valid for use among adolescents.

Alcohol use and religiousness/spirituality among adolescents

BACKGROUND

Previous studies indicate that religiousness is associated with lower levels of substance use among adolescents, but less is known about the relationship between spirituality and substance use. The objective of this study was to determine the association between adolescents' use of alcohol and specific aspects of religiousness and spirituality.

METHODS

Twelve- to 18-year-old patients coming for routine medical care at three primary care sites completed a modified Brief Multidimensional Measure of Religiousness/Spirituality; the Spiritual Connectedness Scale; and a past-90-days alcohol use Timeline Followback calendar. We used multiple logistic regression analysis to assess the association between each religiousness/spirituality measure and odds of any past-90-days alcohol use, controlling for age, gender, race/ethnicity, and clinic site. Timeline Followback data were dichotomized to indicate any past-90-days alcohol use and religiousness/spirituality scale scores were z-transformed for analysis.

RESULTS

Participants (n = 305) were 67% female, 74% Hispanic or black, and 45% from two-parent families. Mean +/- SD age was 16.0 +/- 1.8 years. Approximately 1/3 (34%) reported past-90-day alcohol use. After controlling for demographics and clinic site, Religiousness/Spirituality scales that were not significantly associated with alcohol use included: Commitment (OR = 0.81, 95% CI 0.36, 1.79), Organizational Religiousness (OR = 0.83, 95% CI 0.64, 1.07), Private Religious Practices (OR = 0.94, 95% CI 0.80, 1.10), and Religious and Spiritual Coping--Negative (OR = 1.07, 95% CI 0.91, 1.23). All of these are measures of religiousness, except for Religious and Spiritual Coping--Negative. Scales that were significantly and negatively associated with alcohol use included: Forgiveness (OR = 0.55, 95% CI 0.42-0.73), Religious and Spiritual Coping--Positive (OR = 0.67, 95% CI 0.51-0.84), Daily Spiritual Experiences (OR = 0.67, 95% CI 0.54-0.84), and Belief (OR = 0.76, 95% CI 0.68-0.83), which are all measures of spirituality. In a multivariable model that included all significant measures, however, only Forgiveness remained as a significant negative correlate of alcohol use (OR = 0.56, 95% CI 0.41, 0.74).

CONCLUSIONS

Forgiveness is associated with a lowered risk of drinking during adolescence.

Individual and contextual predictors of severity of marijuana use events among young frequent users

This study used momentary sampling to characterize marijuana events among young frequent users and determine contextual and individual predictors of use severity. Medical clinic outpatients aged 15-24 who used marijuana at least twice a week completed a baseline assessment, then used a handheld computer to report marijuana use at 4-6 signal-prompted times per day and before/after use for 2 weeks. Reports assessed event characteristics (when, with whom, where, how, why, how much, how high). Timestamps identified time, weekend, and duration for each event. Generalized estimating equations tested associations of individual and event-specific contextual characteristics with hits/event, duration, and high. Forty-one youth completed 3868 momentary reports; 40 (98%) reported at least one marijuana use event (N=432 events; M=10.5/participant) and thus provided data for these analyses. Marijuana was most commonly used with other people (74% of events), at home (58%), via blunt (66%), and for social or enhancement reasons (86%). Most events (62%) occurred on weekdays; use was least likely in the morning (8%). Most events involved 6 or more hits (81%). Mean high was 5.2 (out of 8). Of events with start and end times (n=250), mean duration was 46.8 min. Poor mental health and use with a blunt or a bong, in the morning or evening, and on the weekend were associated with 6 or more hits/event. Female gender was associated with greater event duration. Poor mental health predicted higher high. Among youth who used it frequently, marijuana was used in a variety of contexts, with diversity in method, dose, and duration. Contextual factors appeared to predict marijuana dose for a given event, while individual characteristics were more predictive of high and duration.