Program Profile: CHAT (Motivational Interviewing for Adolescents At-Risk for Substance Use)

This program uses motivational interviewing in primary care settings for adolescents at-risk for substance use. This program is rated Ineffective. Results suggest there were no statistically significant differences in alcohol or marijuana use between adolescents who participated in the program and those who did not; however, there was a statistically significant reduction in perceived peer use of alcohol and marijuana for program participants, compared with the control group.

An Ineffective rating implies that implementing the program is unlikely to result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

Program Goals/Target Population

CHAT is a brief motivational interviewing (MI) intervention that aims to encourage long-term positive change for adolescents who use alcohol and other drugs. The MI intervention is delivered in primary care (PC) settings to adolescents (ages 12 to 18) who are identified as being at-risk for substance use. Facilitators engage adolescents in conversations about the negative consequences of unhealthy drinking patterns and marijuana use and help guide them toward healthier life choices.

Program Components

CHAT assesses an adolescent’s motivation to change his or her alcohol and other drug behavior through a brief 15- to 20- minute MI intervention delivered by a trained facilitator. The facilitator asks the adolescent to discuss the pros and cons of alcohol and other drug use, what the adolescent’s friends think about alcohol and other drug use, and how peer use affects the adolescent’s own use. The facilitator next provides normative information about alcohol and other drug use. The adolescent is then asked to discuss what might happen if he or she continues to use alcohol and other drugs.

Depending on the adolescent’s desire to make changes to his or her alcohol and other drug use behavior, the facilitator and the adolescent discuss the adolescent’s willingness and confidence in his or her own ability to reduce or stop alcohol and other drug use. Finally, if the adolescent is willing, they discuss a plan to prepare for high-risk situations where alcohol and other drugs might be present and how to make the healthy choice in those situations.

Program Theory

To reduce adolescent alcohol and other drug use, CHAT uses MI, which is a collaborative, client-centered conversation designed to motivate an individual toward a specific goal by exploring the person’s ambivalence toward change (Miller 1983). MI is commonly used in the treatment of substance use disorders. In CHAT, MI focuses on building a relationship between the facilitator and the adolescent, evoking or drawing out the adolescent’s ideas about change, and emphasizing the autonomy of the adolescent.

In addition to MI, CHAT is based on several social psychology theories. In line with decision-making theory (Kahneman and Tversky 2000), CHAT addresses how adolescents tend to make decisions through hypothesis generation and evaluation (having the adolescents weigh the pros and cons of alcohol and other drug use and brainstorm strategies for behavior change). CHAT program content is also influenced by social learning theory, as it explores how peer behavior, peer norms, and beliefs about peer behavior may influence adolescents’ own alcohol and other drug use (Bandura 1977). CHAT also incorporates the theory of self-efficacy (Bandura 1997), which refers to an individual’s perceived ability to change his or her behavior. CHAT addresses how adolescents who are ready for change might do so, and what that change would look like.

Study

D’Amico and colleagues (2018) conducted a randomized controlled trial of the motivational interviewing (MI) intervention, CHAT, at four primary care (PC) clinics from April 2013 to November 2015. Three of the clinics were in Pittsburgh, Pa., and one was in Los Angeles, Calif. Adolescents between ages 12 and 18 who entered any one of the four clinics for an appointment during the 2.5-year study period were asked to participate in the study by a member of the research team. Although survey materials were provided in English and Spanish and facilitators were bilingual, adolescents were required to speak English to be eligible for the study. Parental consent was required for participants under the age of 18. Eligible adolescents were then screened using the National Institute of Alcohol Abuse and Alcoholism Screening Guide (NIAAA-SG). Those who screened in as at-risk were randomized to either CHAT or enhanced usual care. Each adolescent was invited to complete four web surveys: at baseline, and at 3-, 6-, and 12-months post-baseline. The final follow-up was completed in January 2017. Adolescents who were randomized into CHAT met with a facilitator following completion of the baseline survey and participated in the 15- to 20-minute intervention in a private room without a parent present. Adolescents who were assigned to the enhanced care control group received an alcohol and other drugs (AOD) informational brochure developed by the research team.

The sample included 294 youths. The CHAT group (n = 153) was 59.6 percent female, with an average age of 16. In terms of race/ethnicity, 64.7 percent were Hispanic, 20.3 percent were Black, 12.4 percent were white, and 2.6 percent were multiethnic or other race/ethnicity. Of the adolescents in CHAT, 91.5 percent reported having ever used alcohol in their lifetime, and 82.4 percent reported marijuana use. The comparison or enhanced usual care (UC) group (n = 141) was 55.4 percent female, with an average age of 15.9. In terms of race/ethnicity, 68.1 percent were Hispanic, 12.8 percent were Black,10.6 percent were white, and 8.5 percent were multiethnic or other race/ethnicity. Of the adolescents in UC, 93.6 percent reported having ever used alcohol in their lifetime, and 82.3 percent reported marijuana use. Approximately 19.8 percent of the CHAT group met criteria for an alcohol use disorder, compared with 17.3 percent of the UC group. Additionally, 38.6 percent of the CHAT group met criteria for a cannabis use disorder, compared with 40.7 percent of the UC group. There were no statistically significant differences between the two groups at baseline.

Outcomes were defined as drinking, heavy drinking, marijuana use, negative alcohol consequences, negative marijuana consequences, perceived peer use (of alcohol and marijuana), time spent around peers who use (alcohol and marijuana), and resistance self-efficacy (alcohol and marijuana). Alcohol use, heavy alcohol use, and marijuana use were assessed by asking “During the past [time frame], how many times did you try or use [at least one full drink of alcohol] [drink more than 5 drinks] [marijuana]?” Negative consequences were measured by asking participants to rate how often they experienced a particular negative consequence in the past year or past 3 months on a scale of 0 (never) to 7 (20 or more times). There were six consequences for alcohol, including “doing something they regretted because of drinking” and four consequences for marijuana, including “had trouble concentrating because of marijuana use”. Peer influence was assessed by two items asking about perceived peer use (e.g., “How many in a group of 100 students drink alcohol/smoke marijuana?”) and two items that asked about the amount of time the participant spent around peers who use alcohol or marijuana, rated on a scale from 0 (never) to 3 (often). Resistance self-efficacy (RSE) for alcohol and marijuana was defined as the average of four items from 1 (I would definitely use) to 4 (I would definitely not use) based on different situations (e.g., “if my friend was using” or “if you were bored at a party”). RSE ranged from 1 to 4, with higher scores indicating greater RSE.

Intervention effects were measured using linear regression models with the outcome value at the follow-up periods as the dependent variable. The CHAT indicator was included as the primary independent variable while the outcome value was controlled for at the baseline. Standard covariates such as age, gender, mother’s education, and race/ethnicity were also controlled.

All 153 facilitator-adolescent sessions were digitally recorded and coded for fidelity to CHAT using an adherence checklist (D’Amico et al. 2013). The research team also coded fidelity to motivational interviewing (MI) using the Motivational Interviewing Treatment Integrity (MITI) scale (Moyers et al. 2010). Fidelity to CHAT was 100 percent across all sessions, and all MITI scores were above 4 (4 = competent). Regarding their satisfaction with and the quality of the CHAT intervention, 91 percent of adolescents were satisfied with CHAT, and 92 percent thought the quality of the discussion was good or excellent.

These sources were used in the development of the program profile:

These sources were used in the development of the program profile: