Alcohol consumption and binge drinking increase throughout adolescence. According to 2014 Monitoring the Future data, 9%, 24%, and 37% of 8th, 10th, and 12th graders report past month drinking, respectively.1 These rates are noteworthy because the earlier children initiate alcohol use, the more likely they are to experience alcohol-related problems or an alcohol use disorder later in life.2–4 A strong relationship also exists between early alcohol use and other drug use, sex without contraception, delinquency, school failure, and school dropout.5,6
Many adolescents infrequently visit primary care providers7 and often receive their medical care in pediatric emergency departments (PEDs).8 As many as 1.5 million adolescents use emergency departments as their only source of care.9 These individuals are more likely to report substance use highlighting a need for PED-based alcohol screening.10,11 Furthermore, high school dropouts, who have higher rates of alcohol use compared with those enrolled in school,12 frequently use the PED for health care.13 Consequently, the PED visit can represent a unique opportunity to capture high-risk adolescents missed in other settings.
In screening youth for alcohol use, it is important to identify both those who have alcohol use disorders and those who do not meet full diagnostic criteria but whose alcohol misuse may lead to significant psychosocial and behavioral problems. Medical14,15 and federal16–18 organizations recommend screening and behavioral counseling interventions to reduce alcohol misuse, and have developed resources to support implementation of these services. Although these groups support alcohol screening, brief intervention, and referral to treatment and some have successfully integrated alcohol screening into practice within the PED,19 such screening and interventions are underused and require further research.20 In a recent study of US hospitals that treat injured youth, only 18% reported providing universal alcohol screening for their adolescent ED patients.21 Several self-report screening instruments exist for adolescents including the AUDIT22; CAGE23; FAST24; TWEAK25; CRAFFT26,27; 2-item Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)28; RUFT-CUT29; Newton Screen30; and a single question regarding binge drinking.31,32 None of these measures, however, have emerged as a preferred and widely implemented self-report screen.
In 2011, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) recommended use of a brief adolescent alcohol screen,17 which asks about a patient's drinking frequency and friends' drinking. These 2 items were chosen because drinking frequency has been shown to identify adolescents with alcohol-related problems,33 and some studies demonstrate that the number of alcohol-using friends is the best predictor of an adolescent's alcohol use.34,35 For this reason, asking questions about friends' alcohol use may be an important component of an alcohol screening tool. Initial analyses of the NIAAA 2-question screen indicated that it may be an effective predictor of current and future alcohol problems,36,37 although the screen had not been rigorously tested before its release by NIAAA.37,38
We undertook a validation study to determine the concurrent, convergent, discriminant, and predictive validities of the NIAAA 2-question screen in a large, demographically diverse sample, using 16 PED sites that are part of the Pediatric Emergency Care Applied Research Network (PECARN). This article describes the methodology used by the study, the characteristics of our sample, and baseline outcomes on the NIAAA 2-question screen responses by age, race, ethnicity, and sex.
Initial screening criteria for inclusion in the study included youth who were (1) 12 to 17 years old; (2) seen in the PED for a non–life-threatening injury, illness, or mental health condition; and (3) medically, cognitively, and behaviorally stable. Additional criteria excluded youth who were (1) in severe acute emotional distress (eg, suicidal or suspected by the clinical staff of being a victim of child abuse); (2) cognitively impaired and unable to provide informed assent; (3) unaccompanied by an adult qualified to give written parental permission for the youth's participation in research; (4) unable to read and speak English or Spanish or whose parents were unable to read and speak English or Spanish; and (5) were previously enrolled in this study or had neither a telephone nor an address of residence.
The PECARN, established in 2001, was the first federally funded pediatric emergency care research network and currently consists of 18 PEDs located across the country and a data coordinating center (DCC). Sixteen of the sites participated in this study (see Acknowledgment section). Sites were located in the northeast, middle Atlantic, west, midwest, and southwest, primarily in urban areas. All sites received institutional review board approval before conducting research activities. Because of the potential legal implications of adolescent high-risk behavior (eg, illicit alcohol or drug use), a Certificate of Confidentiality was obtained from the US Department of Health and Human Services.
The PECARN DCC devised a screening schedule, based on site research staff availability, to ensure that the sample was composed of teens who were treated in the PED across a broad range of times, as well as all days of the week. The DCC scheduled five 4-hour screening shifts (3 required, 2 alternate) per site each week. These shifts were typically scheduled for the afternoon and early evening when PED patient volumes were highest. To minimize selection bias, research staff was instructed to approach patients in the order in which they arrived at the PED beginning at a predesignated start time for the screening period.
Sensitivity was used as the basis for our sample size requirements. We assumed a target sensitivity of 90%. For the 95% confidence interval around sensitivity to be within ±2.5%, approximately 5000 participants were needed. Therefore, all sites had the same enrolment goal of 313 patients. Sites enrolled a maximum of 2 patients per shift, resulting in predetermined site enrolment goals of 3 to 10 patients per week. To encourage accelerated enrolment, those sites that enrolled more than 3 patients per week were compensated for any enrolments greater than the weekly minimum. Enrolment occurred between May 2013 and June 2015.
Adolescents who met inclusion/exclusion criteria and their parent(s) were approached by study staff and asked to provide written assent and written parental permission, respectively. Adolescents and parents were made aware of the Certificate of Confidentiality during the consent process. Parents and youth were informed that parents would not have access to their teens' responses and that participant confidentiality would only be breached to protect the safety and welfare of the participant and only in accordance with state and federal law.
Recruitment and study procedures occurred during times when the patient and family were waiting to be seen by a PED clinician or during other waiting periods, which occur in the usual course of ED care. After providing consent, parents completed a contact information questionnaire containing participant address, home phone, cell phone, email address, preferred method of contact, and locator information (if assigned to follow-up). This initial questionnaire and all other study questionnaires were administered through DatStat (Seattle, Wash), a secure, Web-based survey system. Contact information was stored separately from participant assessment battery responses. Locator information was collected at baseline from the participant and their parent for those assigned to the 12- and 24-month follow-up. The locator was contacted in an attempt to obtain updated contact information for any participants who could not be reached with the contact information provided at the time of enrolment.
The adolescent then completed the NIAAA 2-question screen and the criterion assessment battery, described hereinafter, in either Spanish or English. Participants had the option of using an audio computer-assisted self-interview on the web-based questionnaire. With audio computer-assisted self-interview, participants hear preprogrammed audio via headphones for each question when it is displayed on the tablet screen. Questionnaire answers are then recorded by pressing a button on the tablet screen that corresponds to the answer they wish to select. This method permits confidential assessment, which has been shown to increase the veracity of self-reported data on sensitive topics.39,40 For purposes of confidentiality, parents were asked, but not required, to leave the room while the adolescent completed the measures. If parents did not leave the room, they were required to sit out of view of the tablet screen. Administration of the questionnaire could be interrupted if medical care was needed and resumed when the episode of medical care was completed. Although the assessments were in self-report format, the research staff remained nearby to clarify issues or answer any questions. Participants received a $10 gift card for completing the survey.
Two subsamples were, a priori, derived from the entire sample. The first subsample was readministered the NIAAA 2-question screen 1 week after their initial PED visit to assess test-retest reliability. The second subsample is being reassessed at 12 and 24 months with the 2 NIAAA questions and the criterion assessment battery to examine the predictive validity of the 2-question screen. It was possible for participants to be randomly assigned to both subsamples.
A random sample of enrolled participants was contacted by phone and email 7 days after the PED visit to complete the NIAAA 2-question screen for a second time to determine test-retest reliability of the NIAAA 2-question screen. Participant contact within this time frame was required to be included in test-retest analyses. Participants received a $5 gift card for completing this follow-up. Any participant who did not complete the questionnaire within a week of being contacted was considered incomplete and excluded from this analysis.
Twelve- and 24-Month Follow-up
Follow-up at 12 and 24 months after the PED visit is currently underway for a random sample of enrolled youth to assess the predictive validity of the NIAAA 2-question screen. All follow-up assessments will be completed by March 2017. Youths assigned to this group complete a web-based assessment at both follow-up points that includes the NIAAA 2-question screen and the same criterion battery administered at the baseline analysis. Participants receive a $25 gift card after completing each assessment.
Follow-up assessments for participants from all 16 sites are centrally conducted at the principal investigators' site by research staff. Teen and parent reminders are sent via email (or regular mail if a working email address was not provided) 6 months before both the 12- and 24-month questionnaires. In addition, 2 weeks before the 12- and 24-month questionnaire activation dates, a reminder letter is sent via regular mail to the parent and teen. The reminder letter provides basic information about the follow-up procedure and asks participants to call with any updated contact information or whether they want to arrange an appointment to complete the questionnaire via telephone. On the follow-up activation date, a link to the web-based questionnaire is sent automatically via email. Participants have 2 months from the activation date to complete their questionnaire. Reminders are automatically sent weekly to teens and their parents via email), text message, and telephone until either the assessment is completed or participants ask not to be contacted. After the 2-month period, participants are no longer contacted to complete that survey and are marked as an incomplete follow-up. Failure to complete the 12-month follow-up does not preclude 24-month follow-up participation.
Table 1 lists the instruments administered in the criterion assessment battery. The NIAAA 2-question screen was always administered first. However, to control for question order effects, the other assessment battery measures were administered in random order to each successive participant by creating 6 differently ordered assessment battery protocols. Before the start of the assessment battery, research staff provided the participant with the definition and a photo representation of a standard drink (containing 0.6 fl oz of pure alcohol).17 The time frames (past 12 months and past month) used in the questionnaire were reviewed with the participant. The definition of a standard drink and time frames are also reviewed in the follow-up surveys.
We adhered to the screening and risk assignment protocol detailed by NIAAA17 when administering the NIAAA 2-question screen. Two age-specific alcohol questions (past 12-month patient and peer use) are asked. A middle school version (which asks about peer alcohol use first) and a high school version (which asks about the individual's own use first) of the 2-question screen were used. On the basis of their responses, teens were classified into 1 of 4 risk categories: nondrinker, lower risk, moderate risk, and highest risk. Those reporting no days of alcohol use in the past year were classified as nondrinkers. All risk categories were assigned based on age and frequency of past year alcohol use as defined in the NIAAA screening and brief intervention manual.17 For example, 12- to 15-year-olds who reported any alcohol use were classified as either moderate or high risk based on frequency report.
Demographic information (age, sex, race, ethnicity, and school grade) was collected from each participant at baseline. The criterion assessment battery consists of validated measures of alcohol use and misuse, tobacco, marijuana and other drug use, violence, and other risky behaviors. Convergent validity is being assessed using the AUDIT,41 an alcohol screen frequently used to monitor for alcohol use disorders in both adults and adolescents. Concurrent and predictive validity are being assessed with the Diagnostic Interview Schedule for Children (DISC42), a structured, DSM-based interview used to determine substance use diagnoses. The DISC was adapted so that DSM, Fifth Edition, diagnoses could be derived. The concurrent and predictive validity of the NIAAA 2-question screen for other problem behaviors are being assessed by comparing the screen with measures of other drug use (Drug Use Questionnaire-DUQ,43 CRAFFT,27 Newton Screen,30 and DISC42), mental health (Mental Health Inventory-MHI-544), risky sexual behavior (Risk Behavior Questionnaire-RBQ45), and conduct disorder (Global Appraisal of Individual Needs-GAIN46).
Counts and proportions were used to summarize participants' age, sex, race, and ethnicity and their responses to the NIAAA 2-question screen. The Mantel-Haenszel test was used to assess the age-adjusted association between demographic variables and responses to the NIAAA risk assignment. Analyses were performed with SAS software, version 9.4 (SAS Institute, Cary, NC).
All sites successfully screened and enrolled the required number of patients into the study. Figure 1 provides the STROBE diagram for eligibility and enrolment. Of the 12,693 patients screened, 8857 (70%) met inclusion/exclusion criteria. Of the eligible patients, 7545 (85%) were approached. Of those approached, 5114 (68%) consented to participate in the study. Of those consented, 4834 (95%) completed baseline activities and were included in analyses. One hundred thirteen (2%) participants withdrew or discontinued participation during their PED visit. Because of an error in the automated web-based survey, 167 (3%) participants were not asked the NIAAA 2-question screen alcohol use question and were excluded from the analysis. This error was identified and corrected toward the end of recruitment. Two hundred seventy-four participants were assigned to the 1-week follow-up group; 2209 participants were assigned to 12- and 24-month follow-up groups. Some participants (n = 129) were assigned to both follow-up groups. All other participants (n = 2480) only received the baseline assessment in the PED (see Fig. 1).
As shown in Table 2, participants were reasonably well distributed across sex and age. With respect to race (Table 2), almost half identified as white, 26% identified as black, and 16% of the sample did not report a race. As shown in Table 3, approximately one quarter identified as being Hispanic. More than half (59%) of the participants lived with both parents at baseline.
Table 4 details the NIAAA 2-question screen risk levels among participants by age and sex at baseline. As shown in the table, approximately three quarters of participants were nondrinkers. On the basis of the NIAAA criteria, approximately 8% were classified as lower risk, 12% were classified as moderate risk, and 4% were classified as highest risk. (Of note, the NIAAA 2-question screen protocol classifies any past year drinking by youth aged 12–15 y as moderate risk or greater, and thus, no one in that age group was classified as lower risk.) There were no significant sex differences in NIAAA risk level after adjusting for age group (P = 0.1256).
Tables 5 and 6 illustrate the NIAAA 2-question screen risk levels by race and ethnicity. At baseline, approximately three quarters of white participants identified as nondrinkers. Black participants had a significantly larger percentage of nondrinkers (P < 0.0001). Overall, there were significant differences between NIAAA risk levels among white and black participants, after controlling for age group (P < 0.0001). There were also significant differences between Hispanic and non-Hispanic participants' NIAAA risk levels, after controlling for age group (P = 0.0081); non-Hispanic participants were less likely to be drinkers than Hispanic participants.
Early identification of high-risk alcohol use is strongly recommended,14–18 yet there is no consensus with regard to the best alcohol screening tool for adolescents. A preliminary study identified the NIAAA 2-question screen36 as a potential tool for PED clinicians. Our validation study is being conducted to determine the concurrent, convergent, and predictive validity of the NIAAA 2-question screen tool in a large, demographically diverse PED sample. By recruiting from 16 PEDs for this study, our findings should be generalizable to other PEDs nationwide. Furthermore, this study represents, to our knowledge, the largest alcohol screening validation study to date. Smaller validation studies produce sample-specific cutoff scores.47 This study's large sample allows examination of whether the cutoff scores proposed by NIAAA differ across age, sex, race, and ethnicity.
On the basis of the NIAAA 2-question screen, 16% of the PED adolescent patient population screen as either moderate or high alcohol risk, which highlights the need for PED-based alcohol screening. This number is comparable with that reported in other PED studies. In one study of 13- to 17-year-old PED patients, 10% were identified as having alcohol misuse.41 In another PED sample of adolescents 11 to 17 years old, 15.8% of patients had a positive AUDIT score.48 Another study of adolescents 13 to 19 years old treated for an injury in the PED reported that 18% met criteria for a DSM-IV alcohol use disorder.49 Past year alcohol use is similar between this PED sample and the general US teen population. In the current sample, 25% of the participants identify as using any alcohol in the past year compared with 24% of 2014 National Survey on Drug Use and Health participants' report of past year alcohol use.50 With respect to race, we found that alcohol use and NIAAA 2-question screen risk levels were lower among black participants compared with white participants. With respect to ethnicity, we found that alcohol use and NIAAA 2-question screen risk levels were higher among Hispanic participants compared with non-Hispanic participants.
Although this is the largest study of its kind to date, its limitations deserve mention. As a result of human subject protection constraints, we excluded unaccompanied minors from the study. It is conceivable that these individuals may have a different level of risk than those included in this analysis, and thus, our sample may misrepresent risk. Future studies may wish to consider methods to waive parental permission so as to include those who are unaccompanied by a parent or guardian.
Previous research10,11,50 demonstrates that PED patients are more at risk for alcohol use than the general adolescent population. Determining the validity of the NIAAA 2-question screen tool is an important step to identifying the best and most efficient screening tool for use in PEDs. In this study, we successfully recruited a large, demographically diverse sample to establish rates of the NIAAA screen risk categories across age, sex, ethnicity, and race in the PED. Future analyses will address the psychometrics of the instrument and its predictive validity.
The authors acknowledge the PECARN and the participating PECARN sites including Baylor College of Medicine/Texas Children's Hospital; Boston Children's Hospital; The Children's Hospital of Philadelphia; Children's National Medical Center; Cincinnati Children's Hospital Medical Center; Columbia University/Children's Hospital of New York-Presbyterian; Hasbro Children's Hospital; Lurie Children's Hospital of Chicago; Medical College of Wisconsin; Nationwide Children's Hospital; Nemours/Alfred I. duPont Hospital for Children; St Louis Children's Hospital/Washington University; University of California, Davis Children's Hospital-Colorado; and University of Michigan, University of Pittsburgh/Children's Hospital of Pittsburgh of UPMC. The authors' efforts would not have been possible without the commitment of the investigators and research coordinators from these sites. They also thank the following PECARN Steering Committee members: R. Stanley (chair), B. Bonsu, C. Macias, D. Brousseau, D. Jaffe, D. Nelson, E. Alpern, E. Powell, J. Chamberlain, J. Bennett, J.M. Dean, L. Bajaj, L. Nigrovic, N. Kuppermann, P. Dayan, P. Mahajan, R. Ruddy, and R. Hickey. Special thanks to the staff at the Data Coordinating Center including H. Gramse, S. Zuspan, J. Wang, J.M. Dean, M. Ringwood, and T. Simmons for their dedication and assistance throughout the study. Finally, the authors also thank the participants and their parents for participating in this study.
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Keywords:Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
alcohol screening; brief intervention; referral to treatment; SBIRT; adolescent