SafERteens’ main goal is to reduce violent behavior and alcohol use among adolescents admitted to emergency rooms (ERs, hence the capitalized letters in the middle of the program's name). The program also targets attitudes related to violence, specifically drinking and fighting with peers. It is delivered during an adolescent’s treatment in a hospital ER.
The program is targeted at adolescents ages 14 to 18 years who are involved in heavy alcohol use or have come into contact with violence. ER patients ages 14 to 18 years who presented for medical illness or injury are eligible. Patients with acute sexual assault, suicidal ideation, or an altered mental status (physical impairment or instability) are excluded from this program.
The SafERteens intervention can be delivered over a laptop computer or through a trained therapist. In either situation, the 35-minute intervention incorporates goal setting, tailored feedback, decisional balance exercises, and role-playing scenarios.
The computer-guided version is an interactive animated program. Participants sit down with a laptop and headphones and follow the onscreen and audio cues to go through the program. Throughout the intervention, participants are accompanied by an onscreen “buddy” who aids participants in making decisions and understanding the consequences. During role-play scenarios, participants interact with virtual peers and make choices regarding drinking and fighting. Role-play scenarios are tailored to each respondent based on screening and baseline assessments. If a participant reported carrying a weapon, the therapist or computer program present a role-play scenario addressing weapons. There are also role-playing scenarios that address conflict resolution, alcohol refusal, anger management, and drinking and driving.
The trained therapist version of the intervention is similar to the computer-guided version. Instead of interacting with computer software, participants go through the intervention with a trained therapist who engages them in the same exercises and activities. The emphasis remains the same, teaching participants to avoid risky behaviors and scenarios based on the weighing of positive and negative consequences and making healthier choices. The intervention also involves normative resetting and skills training components where therapists or the software work to build participants’ refusal skills, risk avoidance, conflict resolution, and anger management.
Each version of the intervention follows roughly the same format. The first few minutes are spent introducing the intervention material and getting the participant to talk about his or her personal goals. The next few minutes are spent developing a discrepancy between goals/values and current behavior by exploring how drinking and fighting fit into achieving the participants’ personal goals. After this, participants receive personalized feedback based on their screening and baseline assessments and are instructed on the normative behavior of other adolescents their age. This is followed with a few minutes discussing reasons why participants should avoid physical confrontations and alcohol. The remaining time, about 10 to 15 minutes, is spent having participants go through role-play scenarios and decision exercises to incorporate the information they just received. The intervention comes to a close with a summary of what the participant has learned and emphasis on continuing to make healthier and better choices to reach his or her goals and avoid harm.
The SafERteens intervention was developed from adapted motivational interviewing. This technique is well suited to adolescents who have a desire for autonomy and independence, who are resistant to authority, and who are usually unwilling to sit through long interventions. Motivational interviewing addresses changing problem behavior while taking into consideration the aforementioned developmental aspects of adolescents. Adolescents are encouraged to engage in healthy behavior in a respectful, nonconfrontational, and nonjudgmental manner. This method emphasizes individual choice, responsibility for one’s actions, building self-efficacy, and increasing problem recognition. Youths are also informed of the link between their current behavior and any future goals.
Adolescents seeking care in ERs may represent a population that is regularly missed or bypassed through conventional school prevention programs. This population may represent students who have dropped out of school, are frequently absent, or have an increased risk of being involved in violence and using alcohol. SafERteens is designed to be brief and also to be flexible so that it does not interfere with any medical treatment. For example, a session can be interrupted and picked back up if a participant/patient needs to be seen by a doctor or have a procedure performed.
Cunningham and colleagues (2009) used a randomized control trial to study the effect of SafERteens on the attitudes and behaviors of 533 adolescents who had come to an emergency department (ER)seeking medical care. ER patients ages 14 to 18 who presented for medical illness or injury were eligible for the study. Patients with acute sexual assault, suicidal ideation, or an altered mental status (physical impairment or instability) were excluded. This sample was 55 percent African American, 37.2 percent Caucasian, and 6.2 percent Hispanic. It was 42 percent male. All participants completed screening and baseline assessments measuring past alcohol use and instances of violence (e.g., fighting). Then the sample was randomly assigned to either the computer version of the intervention (185 participants), the trained therapist version of the intervention (164 participants), or the control condition (184 participants). Control group participants received educational brochures about the health risks of drinking and ways to avoid violence. The intervention groups received the SafERteens intervention that concentrates on skills training and making healthy choices regarding fighting and alcohol use. Social workers were trained on motivational interviewing techniques and the content of the SafERteens intervention. Therapy sessions were recorded and therapists monitored and given brief retrainings to ensure consistent fidelity.
At the end of the intervention or on receipt of informational brochures, all participants completed a brief posttest. Follow-up assessments were conducted 3 months after the participant’s initial ER visit. These follow-ups were completed at a convenient community location for participants (e.g., library, fast food restaurant). Participants received $20 for the baseline assessment and $25 for the follow-up assessment.
Demographic information, violent behavior, and past medical service measures were collected using survey items drawn from the National Study of Adolescent Health. Weapon carrying and use were measured with items from the Youth Risk Behavior Surveillance System. Substance use was measured with survey items from the Alcohol Use Disorders Identification Test. These items were slightly modified to account for the juvenile population being studied. Attitudes toward, self-efficacy concerning, and readiness to change the use of violence and alcohol were all measured using five-point Likert type scales, ranging from “strongly agree” to “strongly disagree.” Alcohol related items included “driving after drinking is safe as long as you pay attention”; “how sure are you that you could say ‘no’ to drinking if you had problems with your family?”; and “sometimes I think about drinking less.” Violence-related items were similar in composition. These were all attitudinal measures and not measures of actual behavior.
Repeated-measures analyses with an intent-to-treat approach compared the intervention conditions with the control condition on 3-month outcomes for alcohol attitudes, violence attitudes, alcohol and violence self-efficacy, and alcohol and violence readiness to change. An intent-to-treat analysis was used to make the most of all available data and include participants who dropped out of the study.
Walton and colleagues (2010) used a randomized control trial to determine the effectiveness of the SafERteens therapy sessions and computerized interventions against a control condition. ER patients ages 14 to 18 who presented for medical illness or injury were eligible for the study. Patients with acute sexual assault, suicidal ideation, or an altered mental status (physical impairment or instability) were excluded. Participants were recruited in the afternoons and evenings, starting at noon and lasting until 11 p.m., every day of the week. After initial screening, participants were given a computer containing a self-administered survey lasting 15 minutes. Respondents who reported any sort of aggression and alcohol consumption in the past 12 months were selected for the randomized study. Respondents who reported engaging in only one behavior or the other (e.g., aggression or alcohol consumption) were not eligible.
Those selected for the study then took a computerized baseline assessment lasting 20 minutes, for which they received $20. Then participants were randomized into one of three groups: computer brief intervention, therapist brief intervention session, or the control condition. Control group participants received educational brochures about the health risks of drinking and ways to avoid violence. The intervention groups received the SafERteens intervention that concentrates on skills training and making healthy choices regarding fighting and alcohol use. Social workers were trained on motivational interviewing techniques and the content of the SafERteens intervention specifically. Therapy sessions were recorded and therapists monitored and given brief retrainings to ensure consistent fidelity. Follow-up assessments were conducted at 3 months and 6 months from the initial ER visit at a convenient location (e.g., home, hospital, restaurant). Participants were paid $25 for the 3-month follow-up and $30 for the 6-month follow-up.
Alcohol use was measured with the Alcohol Use Disorders Identification Test and the Problem-Oriented Screening Instrument for Teenagers. Binge drinking was considered to be 5 drinks or more. Alcohol consequence measures included items such as school missed and trouble getting along with friends. Violence consequence measures included items such as trouble at school, injuring someone, arguing with friends, and consistent fighting or wanting to fight.
Repeated-measures analyses with an intent-to-treat approach compared the intervention conditions with the control condition on 3-month and 6-month outcomes for occurrence and frequency of violence and alcohol use. An intent-to-treat analysis was used to make the most of all available data and include participants who dropped out of the study.
Both studies report some positive outcomes and significant findings. However, the preponderance of evidence in these studies shows that the program had no effects in changing behaviors.
Cunningham and colleagues (2010) found a significant difference in attitudes toward alcohol and violence, including weapon carrying, for both intervention groups (when compared with the control), at posttest and at 3-month follow-up.
There was a significant difference in levels of self-efficacy for both intervention groups compared with the control. Readiness to change behavior related to alcohol and violence were not significant at posttest for either intervention. At 3-month follow-up, both intervention groups showed a marked increase in self-efficacy for avoiding violence, compared with the controls. This is an attitudinal measure and does not represent actual avoidance of violence. Self-efficacy was measured as a participant’s level of agreement, “strongly disagree” to “strongly agree,” with statements such as “if a person hits you, you should hit them back.” Although significant changes in self-efficacy were noted, readiness to change behaviors related to violence was not significant at posttest for either intervention at posttest or 3-month follow-up.
Abstaining From Alcohol Use
There was a significant difference in levels of self-efficacy for both intervention groups compared with the control. At 3-month follow-up, there was a significant difference in alcohol self-efficacy. However, readiness to change behaviors related to alcohol was not significant at posttest for either intervention at posttest or 3-month follow-up.
Occurrence and Frequency of Violence
Walton and colleagues (2010) measured the occurrence and frequency of violence through severe peer aggression, any experience of peer violence, and any violence consequences. Participants in the therapist intervention were significantly less likely than the controls to report any severe peer aggression, experience of peer violence, or violence consequences at 3-month follow-up. These significant effects were not evident at the 6-month follow-up. That is, any beneficial effect of the intervention was short in duration and not detectable at 6 months.
The number of violence consequences at 3-month follow-up was significantly lower for the intervention group than for the control group. However, at 6-month follow-up, this effect was not evident. Additionally, there were no significant effects for any of the other measures of violence at 3-month and 6-month follow-ups.
Occurrence and Frequency of Alcohol Use
Alcohol use was measured by alcohol misuse, any binge drinking, and alcohol consequences. For almost all of these behaviors, there were no significant effects for the treatment group at 3-month and 6-month follow-ups. The only significant finding was that, at the 6-month follow-up, participants in the treatment group were less likely than control subjects to report alcohol consequences. There were no significant effects for the frequency alcohol use, across any of the three measures, at either the 3-month or 6-month follow-up.