Adaptive Interventions to Reduce Risky Drinking and Violent Behaviors among Adolescents

 说明(申请人提供)：未成年饮酒和暴力行为(即身体攻击)在青少年和初出茅庐的成年人中很普遍，对发病率和死亡率有巨大影响，特别是在居住在社会经济条件不利的城市环境中的青年中。城市急诊部(ED)的访问提供了一个机会，可以识别参与这些共同危险行为的年轻人，并提供干预措施来改变危险轨迹。尽管我们之前的工作(SafERteens研究)取得了令人振奋的发现，证明了基于ED的酒精和暴力短暂干预(BI)在减少与酒精相关的后果和暴力行为方面的有效性，但单次BIS对公共健康的影响受到适度影响的限制。此外，严重缺乏关于如何优化干预措施以在节省资源的情况下产生最大影响的数据。顺序、多分配随机试验(SMART)设计提供了一种创新的方法，以比较基于反应/无反应的即时适应性干预[(文本消息(TM)或远程健康教练(HC)])对青少年的疗效。到目前为止，这种个性化的适应性干预措施还没有应用于青年中的危险饮酒和/或暴力行为。拟议的研究利用对青年特别有吸引力的技术，促进适时提供适应性干预(AIS)。因此，具体目标是：1)比较人工智能的有效性，从以下几个方面入手 BI+TM与BI+HC在减少青少年在ED期间的酒精滥用和暴力行为方面的比较；以及，2)为那些最初有反应的人和那些没有反应的人确定最有效的第二阶段教育后访问策略。具体来说，在ED筛查中，700名酒精使用和暴力行为阳性的青少年(14-20岁)将被随机分配到BI+TM或BI+HC。在接受教育署的SafERteens BI后，青少年将在8周内完成每周一次的文本评估，以量身定制干预内容和衡量变化机制，并在一个月内确定参与者的反应(例如，酗酒、暴力行为)。每个手臂中的应答者将被重新随机分配到持续状态(例如，维护)或减少状态(例如，退出)。无响应者将被重新随机分配到持续状态(例如，维护)或强化状态(例如，加强)。结果将在基线后4、8和12个月进行衡量。将对认可机构进行打包，以最大限度地增加未来的翻译，并提供成本数据(例如，总实施成本、避免的每项活动的成本)。次要目标是：1)比较和对比预先指定的嵌入人工智能的主要和次要结果；以及，2)确定人工智能疗效的基线和随时间变化的调节因素。鉴于与饮酒和暴力有关的病态/死亡率，拟议的研究将通过在智能设计中嵌入一项比较功效研究、测试最先进的干预提供方法(短信、远程治疗)，以确定在高危青年中产生和维持成果的最佳干预战略，从而对公共卫生产生重大影响。

 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.