Adaptive Interventions to Reduce Risky Drinking and Violent Behaviors among Adolescents

 描述（由申请人提供）：未成年饮酒和暴力行为（即，暴力（人身攻击）在青少年和初成年人中普遍存在，对发病率和死亡率产生了巨大影响，特别是对居住在社会经济弱势城市环境中的青年。城市急诊室（艾德）的访问提供了一个机会，确定参与这些共病风险行为的青年，并提供干预措施，以改变风险轨迹。尽管我们之前的工作（SafERteens研究）显示了基于ED的酒精和暴力短暂干预（BI）在减少酒精相关后果和暴力行为方面的有效性，但单次BI对公共卫生的影响受到适度效应大小的限制。此外，严重缺乏关于如何优化干预措施以在资源有限的情况下产生最大影响的数据。序贯、多分配随机试验（SMART）设计提供了一种创新方法，根据响应/无响应比较青少年即时适应性干预[（短信（TM）或远程健康教练（HC）]的疗效。迄今为止，这种个性化的适应性干预措施尚未应用于青少年的危险饮酒和/或暴力行为。这项拟议的研究利用了对青年特别有吸引力的技术，以促进及时提供适应性干预措施。因此，具体目标是：1）比较开始 BI+TM与BI+HC在减少艾德治疗期间青少年酒精滥用和暴力行为方面的比较; 2）确定艾德治疗后访视最有效的第二阶段策略，适用于最初有反应和无反应的患者。具体而言，将700名在艾德筛查中酒精使用和暴力行为呈阳性的青年（年龄14-20岁）随机分配至：BI+TM或BI+HC。在艾德接受SafERteens BI后，青少年将在8周内完成每周文本评估，以定制干预内容并测量变化机制，并在一个月内确定参与者的反应（例如，酗酒，暴力行为）。每组中的应答者将被重新随机分配至持续状态（例如，维持），或降低的条件（例如，下台）。无应答者将被重新随机分配至持续状态（例如，维持），或强化条件（例如，升级）。将在基线后4、8和12个月测量结局。AI将被打包，以最大限度地提高未来的翻译，并提供成本数据（例如，总实施成本，避免的每个事件的成本）。次要目标是：1）在主要和次要结局方面比较和对比预先指定的嵌入式AI; 2）确定AI疗效的基线和随时间变化的调节因子。鉴于与酒精使用和暴力相关的发病率/死亡率，拟议的研究将通过嵌入一项比较疗效研究，测试最先进的干预提供方法（短信，远程治疗），在SMART设计中确定最佳干预策略，以产生和维持风险青年的成果，从而产生重大的公共卫生影响。

 DESCRIPTION (provided by applicant): Underage drinking and violent behaviors (i.e., physical aggression) are prevalent among adolescents and emerging adults, with enormous impact on morbidity and mortality, particularly among youth residing in socio- economically disadvantaged urban settings. An urban Emergency Department (ED) visit provides an opportunity for identifying youth involved in these comorbid risk behaviors and delivering interventions to alter risk trajectories. Despite promising findings from our prior work (the SafERteens Study), which demonstrated the efficacy of an ED-based brief intervention (BI) for alcohol and violence on reducing alcohol-related consequences and violent behaviors, the public health impact of single session BIs is limited by modest effect sizes. Further, there is a critical lack of data regarding how to optimize interventions to have maximal impact with parsimony of resources. Sequential, multiple assignment randomized trial (SMART) designs provide an innovative methodology to compare the efficacy of just-in-time adaptive interventions [(text messaging (TM) or remote health coach (HC)] for adolescents based on response/non-response. To date, such personalized adaptive interventions have not been applied to risky drinking and/or violent behaviors among youth. The proposed study harnesses technology which is particularly appealing to youth, for facilitation of just-in-time delivery of adaptive interventions (AIs). Thus, the specific aims are to: 1) Compare the efficacy of AIs that begin with BI+TM vs. BI+HC on reducing alcohol misuse and violent behaviors among youth while in the ED; and, 2) Identify the most efficacious second-stage strategy post-ED visit for those who initially respond and for those who do not. Specifically, 700 youth (ages 14-20) in the ED screening positive for alcohol use and violent behaviors will be randomly assigned to: BI+TM or BI+HC. After receiving the SafERteens BI in the ED, youth will complete weekly text assessments over an 8 week period to tailor intervention content and measure mechanisms of change, with one month determination of participant response (e.g., binge drinking, violent behaviors). Responders in each arm will be re-randomized to continued condition (e.g., maintenance), or reduced condition (e.g., stepped down). Non-responders will be re-randomized to continued condition (e.g., maintenance), or intensified condition (e.g., stepped up). Outcomes will be measured at 4, 8 and 12 months post-baseline. The AIs will be packaged to maximize future translation, with cost data provided (e.g., total implementation cost, cost per event averted). Secondary aims are to: 1) Compare and contrast pre-specified embedded AIs in terms of primary and secondary outcomes; and, 2) identify baseline and time-varying moderators of AI efficacy. Given the morbidly/mortality associated with alcohol use and violence, the proposed study will have significant public health impact by embedding a comparative efficacy study, testing state-of-the- art intervention delivery approaches (text messaging, remote therapy), within a SMART design to identify the optimal intervention strategy to produce and sustain outcomes among at-risk youth.