Mini Review - (2016) Volume 2, Issue 1
Winters Consulting Group, USA
Received date: January 08, 2016; Accepted date: January 19, 2016; Published date: January 26, 2016
Citation: Winters KC, Brief Interventions for Adolescents. J Drug Abuse. 2016, 2:1.
Public health concerns regarding adolescent alcohol and other drug involvement emphasize the need for continuing research to develop and evaluate preventive interventions for use in a variety of settings. This focus includes research on brief interventions. This short commentary piece provides an overview of the brief intervention literature and highlights future directions.
The development and empirical investigation of brief interventions (BIs) to address adolescent alcohol and other drug involvement is an emerging area of interest to clinicians, researchers and policy makers. On a general level, BIs are attractive given that they are brief, efficient, cost-conscious, teachable to a wide range of service providers, and clinically applicable for a sizeable percentage of substance users with a mild-to-moderate problem [1]. Moreover, BIs are particularly fitting for adolescents: the content can readily be organized around a developmental perspective; many substance-using teenagers do not need intensive, longterm treatment; and the client-centered, non-confrontational interviewing approach common to BIs be likely appealing to youth. Also, a BI program is the core component of the SBIRT (Screening, Brief Intervention and Referral to Treatment) model, an approach with concordant growth in popularity [2]. (See recent research initiative focusing on adolescent SBIRTs by the Conrad N. Hilton Foundation, https://www.hiltonfoundation.org/ priorities/substance-use-prevention).
BIs may be clinically relevant to the approximately 25% of teenagers who meet criteria for a Mild or Moderate Substance Use Disorder, based on criteria in the Diagnostic and Statistical Mental Manual-5th Edition [3], or show other high-risk patterns of drug involvement (e.g. binge drinker; use of an illicit drug) [4, 5]. Common features of most BIs for adolescents include a motivational interviewing style by the counsellor, engaging the teenager in a discussion of the advantages and disadvantages of drug use (“pros and cons” exercise), and negotiating realistic and specific drug reduction or abstinence goals [6]. Some BIs also include the exercise in which typical use of alcohol or other drugs for the teenager’s age group is discussed (“normative feedback”). BIs for adolescents range from a brief conversation to a few counselling sessions and have occurred in a variety of settings, such as school health clinics, juvenile drug courts and detention centers, and pediatric and emergency departments.
There are numerous literature reviews and a few meta-analyses on the effectiveness of BIs with adolescents. For example, a recent meta-analysis [7] of 45 brief alcohol interventions (reported in 24 studies) found that relative to no treatment or treatment as usual, brief alcohol interventions were associated with significant reductions in alcohol use and alcohol-related problems. These favourable results were also relatively consistent across the different therapeutic approaches, delivery sites, delivery formats, and intervention length.
Nonetheless, exceptions as to the efficacy of BIs exist. Walker and colleagues caution that a BI for adolescents who are chronic marijuana abusers may not be effective [8], and there are similar cautions in the adult literature [9]. As Saitz has noted in an interview, "In retrospect, drug use is a complicated problem. While there might have been some hope that something as simple as this would work, it now appears it doesn't. A few minutes of counselling is not going to change that." (Interview with R Saitz, Boston University Medical Center, August 5, 2014).
As with any emerging therapy model, several issues pertaining to outcome and implementation of BIs for adolescents merit more research attention.
Traditional variables that have been viewed as influencing the efficacy and effectiveness of any treatment program include timing, frequency, and intensity of exposure to the program [10]. Research has not yet clarified yet how these variables are associated with the effectiveness of adolescent BIs, although there are indications that a single counselling experience may yield as much impact as multiple sessions [7].
Another perspective that merits more research attention questions the value of a fixed, manualized intervention. In this light, such standardized programs may be limited because the program fails to take into account that individuals are heterogeneous both in their intervention needs and in their response to various intervention frameworks [11]. Adaptive or tailored strategies optimize outcomes by individualizing the intervention option [12]. Applying this notion to BIs could provide a framework that specifies when and how the type or intensity of a specific intervention should be adjusted depending on tailoring variables. Examples of tailoring variables include may include pre-intervention, adolescent characteristics [13], adolescent preferences when given a choice of program delivery or content, or the client’s progress through the program. Also, tailoring variables may be based on features or forms of a BI; variables of interest here are the setting in which the program is implemented, how many sessions, individual vs. group administration, the use of booster sessions, the inclusion of parents, and what counselling components are essential (e.g., decisional balance exercises; goal-setting).
Nearly all studies of adolescent BI’s have limited their outcomes to no more than one year. To what extent, if at all, a brief counselling experience can influence extended health remains an open question. A related issue is what mechanisms of change are associated with extended behaviour change when it occurs. Do BIs promote self-directed changes, changes in the home (e.g., changes in parenting practices), or additional counselling? Regarding the latter point, the role of BIs in triggering a referral to treatment has not been formally studied. The recent research attention of SBIRT for adolescents, as already noted, provides an opportunity for “RT” research questions to be addressed.
More work is needed to determine to what extent the effectiveness of BIs are dependent upon implementation features. Traditional essential principles of successful implementation include that the core program components are delivered with fidelity; absence of barriers such as unavailable transportation, not enough time to deliver a minimum of intervention dosage, and scheduling problems; and service providers being sufficiently trained and supervised [10]. Regarding the latter point, a recent study showed that the effectiveness of BIs was associated with counsellors who were proficient in client-centered counselling and motivational interviewing [14].
Implementation becomes more complicated with the use adaptive models. For example, fidelity to deliver content and the skill level of the service provider may be more difficult when program content changes based on tailoring rules. Also, practical problems may arise when the tailoring guidelines suggest the need for parent involvement, but the teenage client may refuse to participate if a parent is involved. Also, consider the challenges of an adaptive model that includes booster sessions after the core program because of poor clinical progress but the setting may not have the resources to accommodate the additional sessions.
The use of alcohol and other drugs by adolescents persists as a major public health issue in the United States. The BI approach holds great promise to expand services to a wide range of youth in diverse and non-traditional settings. A sizeable number of rigorous studies offer encouragement that BIs (and the related SBIRT model) are effective in adolescents involved with drugs. Progress is being made in teasing out the pathways through which BIs are exerting their effects, and adaptive models, despite challenges, may be a fruitful direction for a new generation of preventive interventions. These trends highlight the need for continuing research to develop effective brief interventions to address adolescents whose drug problem has not progressed to a severe level.
This study was supported by grants DA017492 and AA14866 from the National Institute on Health.
